Thank you for choosing us as your dental health care provider. We are committed to dental excellence, superior quality, and outstanding customer service. Payment of your bill is considered part of your treatment. The following is a statement of our financial agreement, which outlines our office policies. Please read and sign this form prior to beginning any treatment.
Full payment is due at time of service. We accept cash, checks, Visa, Mastercard, American Express, or Discover. If you have an extended treatment plan we do offer payment plan options
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All co-payments and deductibles are due on the date of service. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract, therefore, the balance of your bill is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us all of your insurance information. All major services have to be pre-approved for benefits by your insurance carrier.
Usual and Customary Rates:
Our practice is committed to providing the best treatment for our patients and our fees are based on a variety of factors specific to our practice and our area. The insurance program you or your employer have chosen may base its dollar allowance on a fee schedule, which may not coincide with our practice’s current fees, and you will be responsible for the remaining balance. The insurance company often has its own arbitrary way of determining what is usual and customary.
Unless cancelled at least 24 hrs in advance, our policy is to charge for missed appointments. Please help us serve all our patients better by keeping scheduled appointments.
If an appointment with a hygienist is missed without 24 hour notification there will be a $30.00 fee assessed to that family members account.
If with-in a 2 year period, a second appointment with a hygienist is missed without proper notice, a $75.00 fee will be assessed to that family members account.
If an appointment with the doctor is missed without 24 hour notification, there will be a $50.00 fee assessed to that family members account.
If, within a 2 year period a second appointment with the doctor is missed without proper notice, a $100.00 fee will be assessed to that family members account.
Future appointments cannot be scheduled until the missed appointment fees are resolved.