Our experience has shown that it is helpful to have an understanding with our patients as to our office financial policy. For your convenience and information, we offer several methods of payment for your dental care. You may choose the plan which you prefer.
1. Payment in full at time of services is rendered.
We accept MasterCard, Visa, Discover, and American Express.
We also offer our in-house financing with Care Credit,
Citi Health Card and Capital One.
2. Dental insurance: Patients co-payment and deductible is
Expected at time of service
As a courtesy to you, we will submit dental claims and accept assignment of benefits. All dental services may not be a covered benefit of your insurance, even if you have dual coverage. We will contact your insurance company to verify benefits; however, this is not a guarantee of payment!! Patients are ultimately responsible for the discovery and understanding of any applicable insurance benefits. Dental insurance is a contract between the patient, employer and the insurance carrier; not between the dentist and the insurance carrier. Thus, patients are ultimately responsible to this office for all fees and financial charges incurred, regardless of the insurance companies benefit policy.
A finance charge of 18% will be added to accounts with an unpaid balance after 90 days.
Cancellation/Failure to show Policy;
Appointment failures and cancellation with less than a 48 hour notice may result in a minimum $50.00 -$75.00 charge to the patient. Multiple failures may result in same day availability appointment only or dismissal from our practice.
In the event a patient’s account is turned over to a collection agency for failure to abide by these financial terms. The patient will be liable for all collection fees, attorney fees and court costs.
I authorize the release of any information required during the course of my treatment necessary to process insurance claims.
I hereby authorize payment of dental benefits, otherwise payable to me, to be made directly to this office.
I have read the financial agreement completely and understand the above financial policy. I agree to abide by this policy and conditions as stated.
I understand that I am ultimately responsible to this office for all fees and financial charges incurred, regardless of my insurance benefits and the payment methods selected.