PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF SERVICE
As a favor to you, we will file your insurance claims.
Please note that it is the responsibility of the patient to inform us of
any change in your employer or insurance coverage.
If you have dental insurance, you will be required to pay your deductible and
ESTIMATED PORTION of the fee, if any, at the start of
service. You will also be responsible for any balance remaining after your
insurance company has paid on your claim, since their
ESTIMATES of coverage are not a guarantee of payment, but
merely an estimate over which we have no control.
While the filing of insurance claims is a courtesy that we extend to our
patients, we must emphasize that as dental care providers our relationship is
with the patient, NOT the insurance company. If we do not
receive payment from your insurance company within a reasonable amount of time
(60) days, the balance will become your responsibility. A
monthly interest charge of 1.50% will be charged after 60
A fee of $50.00 will be charged for any appointment cancelled
without 24 hours notice.
A fee of $25.00 will be charged for any returned checks.
In an effort to provide you with flexible payment arrangements, we have
expanded our payment policy.
PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT
Please make your choice, sign below and return to office manager before
Our office is a fully approved and accredited user of the Visa and MasterCard
Health Care Program which will enable you to use your Visa and MasterCard to
automatically cover amounts not paid by your insurance. You may also choose a
comfortable amount to be automatically billed to your Visa or MasterCard on a
If none of the above options apply, please see the office manager. Thank you