Thank you for choosing our office. We are comitted to providing you with the best possible care. If you have any questions regarding fees for treatments, please feel free to discuss them with us. We will make every effort to avoid misunderstandings and preserve our relatioship.
Payment for services is due at the time treatment is rendered. If you have dental insurance, we are anxious to help you receive maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policies. We will be happy to process your insurance claims for reimbursement as well as accept insurance assignment from insurances we are participating providess with. Our office is provided with :general benefit" information from your insurance, which is not specific or a guarantee exact amounts to be paid by your insurance carrier. If there is any remaining balance after your insurance has processed your claim, the balance is your responsibility.
Missed and broken appointments waste valuable manpower and raise fees for everyone. In an effort to reduce this expensive waste there will be a charge of $75.00 for broken or missed appointments. A broken appointment is classified as the failure to appear for an appointment, cancellation not made 48 hours in advance or lateness that results in an inability to complete scheduled treatment.
Returned checks due to insufficient funds or closed accounts will have a $35 charge.
If your account must be placed in the hands of a third party for collections, your account will be charged 1/3 of the total balance for collection fee.
If you have any questions about the above information or any uncertainty regarding your insurance coverage, please do not hesitate to ask us.
I read the above conditions of treatment and payment and agree to their content.
Signature if guarantor of payment/responsible party: