Financial Policy

PATIENTS WITH DENTAL INSURANCE:
- Be prepared to pay your estimated portion of the dental fees at the time of service. Once we receive payment from your insurance company we will send you a statement showing their payment and your remaining balance.
- We bill all insurance companies as a courtesy to you, but are contracted with Blue Cross and Blue Shield, Dental Dental only. We will help you collect the insurance funds that are due to you - however, should they refuse to pay, the balance is your responsibility.
PATIENTS WITHOUT DENTAL INSURANCE
- Payment in full is due at the time of service. For treatment that requires more than one appointment (such as a crown or bridge) you may make two payments, one at each appointment, given that the first payemnt covers at least half of the full amount due. We offer a 5% discount to those who pay in full, with a check or cash, on the date of service.
FINANCIAL POLICY FOR ALL PATIENTS
We bill monthly statements, up to 3 months. If payment is not received in full within 120 days, your account will be turned over to our billing agency, AR Services. Please further understand that a finance charge of 1.5% per month will be added to any overdue balance.
Please accept by checking each box:*
- Should your account be sent over to our billing agency, you are responsible for and agree to pay to pay all resonable costs of collection or attorney fees.
- A $30 fee may be assessed for returned checks.
- If a dental bill continues to go unpaid without a payment plan, further treatment may be refused.
- We accept Visa, Mastercard, and Discover for your convenience. We offer financing with CareCredit with no interest up to 6 months, as well as extended payment plans for those who qualify.
- We offer a 5% senior citizen discount for those over the age of 65.
BROKEN APPOINTMENTS
- We encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hours notice to avoid a $25/hour cancellation fee (emergencies are an exception).
AFTER HOURS EMERGENCIES
- In the event of an emergency after regular business hours a $150 emergency fee will be charged in addition to the necessary treatment fees.
By signing below, I acknowledge that I agree and accept the financial policy as outlined. I authorize and request my insurance company to pay directly to the dentist all benefits. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services provided on my behalf or my dependents.
Name*
First Last
Today's Date*
Signature*
Phone
This field is for validation purposes and should be left unchanged.

Follow Us on Facebook!

Financial Policy

PATIENTS WITH DENTAL INSURANCE:

PATIENTS WITHOUT DENTAL INSURANCE

FINANCIAL POLICY FOR ALL PATIENTS

BROKEN APPOINTMENTS

AFTER HOURS EMERGENCIES

Repair a Tooth

Replace a Tooth

Dental Enhancements

Remove a Tooth

Preventive Care