OFFICE POLICIES

EXPECTED PAYMENT
To keep our fees to you as low as possible, we ask that payment be made at the time of service. For your convenience you will be provided an estimate for services in advance of your appointment/s to ensure your opportunity to plan in advance for your dental care. We believe whether you privately pay or have dental insurance to assist you, everyone deserves the care they need and want.   Initials    

DENTAL INSURANCE
We are happy to file your dental claims to assist you in receiving the full benefits of your coverage. We request you familiarize yourself with your insurance benefits, and provide us the correct information to assist you with the submittal of claims. We will accept the estimated insurance payment directly from your insurance company provided payment is received from them within 45-60 days. Please remember, your insurance is a contract between you, your employer, and the insurance company; therefore, we cannot guarantee coverage. Not all services are covered benefits in all contracts; therefore, you are ultimately responsible for the total amount of your dental fees. The treatment recommended for you is indicated regardless of your dental insurance benefits, deductibles, limitations, or maximums.   Initials    

PAYMENT OPTIONS
For your convenience we provide a variety of payment options to help you receive the quality care you need to enjoy a healthy and confident smile. Please identify which form of payment is most convenient for you at the time of service. We accept Cash/Check/Credit Card. Please Note: A $25.00 NSF fee will be charged for all returned checks. Should you desire a monthly payment plan we invite you to complete a simple finance company application. There are no application fees or a down payment and the plan can be interest-free.   Initials    

PAST DUE BALANCES
If applicable balances owing from a prior visit where insurance is not pending, or an insurance payment has not been received within 90-days, or the account has been sent to collections is considered past due. Payment of any past due balance is required to be paid in full before incurring new charges. All balances over 60-days are subject to a $10.00 rebelling fee.   Initials    

CANCELLATIONS
To ensure that we can provide timely care to all patients, we require adequate notice of appointment changes. A missed appointment fee of $75.00 per hour of scheduled time may be assessed if an appointment is missed or canceled without sufficient notice. For purposes of this policy, sufficient notice is defined as at least 48 business hours prior to the scheduled appointment time. This fee is intended to offset the cost of lost appointment time and may not be covered by dental insurance. Repeated missed or late-canceled appointments may result in dismissal from the practice. Exceptions may be made in the event of unforeseen emergencies, at the discretion of the provider.   Initials    

INFORMATION CHANGES
To ensure your records are current please notify us of any changes related to medical history, telephone number/s, address, employer or insurance information as they occur.   Initials    

My signature indicates that I understand that policies as outlined and any questions I have with regard to office policies have been answered.