1. If you do not have dental insurance or your insurance will not pay our office directly, the following will apply: Your entire balance must be paid in full at the time of service. We do offer a courtesy discount for treatment paid in full on the first-day treatment begins. Financing is available for large treatment plans- ask for details.
   
   
2. As a courtesy to our patients, this office will submit all primary dental claims and pre-treatment authorizations to the insurance company. You, the patient, are responsible for ALL amounts, whether reimbursable or not, by your insurance. Any payment coverage information, which you receive from your insurance company, should be considered an estimate. Your actual coverage may be less, and many necessary dental procedures are not covered by dental insurance.
   
   
3. If your dental insurance will not send insurance payments to our office (assignment of benefits), you are responsible for paying your bill in full on the day of service. Any insurance checks sent here in error will be signed over to the patient, providing there is a zero balance.
   
   
4. Any treatment requiring more than one visit may be paid in installments as a courtesy. For example, crowns, bridges and dentures require 2-3 visits. A minimum down payment is required for each procedure. The balance will be divided accordingly, and the balance must be paid in full on or before the day of completion.
   
   
5. If your balance is overdue for more than 30 days, it will be assessed a 1.5% finance charge per month, 18% annum. A $2.00 minimum will be charged per overdue bill. Patients who have a balance due and, special arrangements have not been made and adhered to will not be reappointed until their balance is paid in full.
   
   
6. Written price quotes are good for a 3 month period only. Prices are subject to change without notice.
   
   
7. Cancellations MUST be made 24 hours in advance, or there will be a minimum $35.00 charge to your account. This is a firm policy.
   
   
8. Occasionally a visit may be scheduled when the doctor is not in the office. I agree to receive dental hygiene services without a dentist present with prior notification. I will have been examined by Dr. Baker within the prior seven months, and I understand that a prescription for these services is written in my chart. I agree to provide updated medical information, including any prescription medications, at each visit.
   
   
9. I acknowledge receipt of our Notice of privacy practices and consent to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations.

I {patientName} have read the payment policy of Susan M. Baker, DDS, and understand my obligations.