In an effort to avoid misunderstandings and
to keep the high cost of billing to a
minimum, thereby being able to maintain fees
at a reasonable level, we are presenting you
with a statement of the office policies
concerning payment of your account and the
processing of your insurance.
This office is happy to cooperate with the
patients who are covered by insurance.
INSURANCE COVERAGE IS A CONTRACT BETWEEN YOU
AND YOUR INSURANCE COMPANY.
We ask that you read your policy to be sure
that you are aware of any limitations of the
benefits provided. It is important to
understand that in most cases your insurance
is designed to reduce your cost, NOT
eliminate it completely. You are
ultimately responsible for the full amount
of your bill, regardless of your insurance
coverage. The office will provide you
with an ESTIMATED COST of services to be
rendered. It is not the responsibility
of the office to verify insurance coverage,
rules, maximum or participation.
Payment is expected at the time of
treatment. The office accepts use of
MasterCard and Visa. In the event my
account becomes delinquent and becomes
assigned to a collection agency, I agree to
pay all collection agency fees, court costs
and attorney fees. I understand that
all accounts with a balance over 30 (thirty)
days will be assessed a 1.5 percent late
charge per month on the unpaid monthly
balance or $25 per month (at the office's
discretion). Any checks returned to
the office are subject to an additional fee
of $35.00. Immediate remittance in the
form of cash. money order or certified funds
Occasionally, during a surgical procedure,
situations are encountered that require
additional services, which could not be
anticipated beforehand. Fees for these
additional services will be charges at the
time of treatment.
We are now able to offer 6 month interest
free financing is available on any work over
$500 through Care credit. Please ask
the receptionist for more details.
Patients under the age of 18 MUST BE
ACCOMPANIED BY A PARENT OR LEGAL GUARDIAN.
All fees involved must be paid by the
guardian present at the time of service.
This office will not bill another party or
guardian for the minor patient.
Please be advised that our office will be as
flexible as possible to meet your needs in
scheduling appointments. Kindly
give 48 hours’ notice prior to canceling an
appointment in order to avoid a charge of
$30 per 30 minutes of appointment time.
Print and Complete
this form before your first visit to our