Financial Agreement
As the responsible party, this agreement is to inform you of your financial obligation to our practice. This financial agreement is intended to facilitate excellent service to you and your family while minimizing our administrative costs.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. If payment from your insurance company is not received within 60 days from date of service, you may be expected to pay the balance in full.
As a courtesy to you we will help you process all your insurance claims. We require that you direct your insurance company to pay your benefits directly to our office by signing the authorization provided by our front office staff. In order for our office to file your insurance claim, you must bring proof of insurance at each appointment.
- Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time service is provided. Your co-payment may be adjusted after the time of service depending upon the final reconciliation of insurance payments. Our office accepts cash, personal checks, MasterCard and Visa. Additional financing is available through CareCredit upon request and approval.
- Returned checks and/or balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month (18% annually). Additionally, our office may charge you for broken appointments and appointments cancelled without 48-hour advance notice.
- A $180 deposit may be required to schedule a conscious sedation appointment (it is $200 for a general anesthesia appointment). This deposit may be in the form of a check or credit card. We will not deposit the check or charge your credit card unless the appointment is broken with less than 48 hours notice.
- If you have any questions regarding this financial agreement, please ask. We are committed to providing you with the most positive experience in dental care.
- A copy of this Financial Agreement is available upon request.