Thank you for choosing our office as your dental care provider. We are committed to providing quality care for our patients. We are providing you this policy so you have a clear understanding of our Patient Financial Policy. This is important for our professional relationship. Please ask if you have any questions regarding our fees, policies or your responsibilities and we will be happy to assist you. You will need to read and sign this form before your visit.

It is the patient's responsibility to provide our office with your current insurance information. We will ask for your insurance card at your first visit. We may request another copy of your insurance card at another visit to update your records, so please have your insurance card every time you come to our office. If current information is not obtained at the time of service, it will become the patient's responsibility to pay until current information is provided. If a problem occurs with your claim you may be asked to contact your insurance company to help resolve the problem. You will also be expected to make payments on your account until the balance is paid in full.

Your insurance policy is a contract between you and your insurance company. As a courtesy to you, we will file your claims for you however we will not become involved in disputes between you and your insurance carrier. This includes, but is not limited to, deductibles, co-payments and non-covered charges. We will supply information as needed. Should your insurance carrier or policy change during your course of treatment, there may be a difference in reimbursement. We will do our best to explain the difference, however any difference is ultimately your responsibility.

You are ultimately responsible for your account. Payment in full is due at the time services are rendered unless financial arrangements are pre-arranged with a financial coordinator. We accept Visa, Mastercard, Discover, cash or personal checks. We also offer financing through Care Credit, subject to pre-approved. If a personal check is returned from the bank a $25.00 service charge will be applied to your account.

I have read this policy and understand and agree to this policy: