We are committed to providing you and your child the best possible care. If you have dental insurance, we will help you receive your maximum benefits. In order to do this, we need your assistance and your understanding of our financial policy.
The parent/legal guardian accompanying a minor (under 18 years old) is responsible for full payment.
Regarding Divorced Parents
We cannot be responsible for disputes between parents due to divorce/separation. The parent or legal guardian signing this form will be responsible for the account. If the courts hold a specific parent responsible for providing healthcare/dental coverage, the dispute is between the parents and will not be arbitrated by our office.
Regarding Non-Insured Patients
Full payment is due at the time of service. We accept cash, checks, Visa and Mastercard. Information regarding outside extended payments plans is also available.
Regarding Insured Patients
Estimated Non-insured portions for treatment rendered is due at the time of service. Balance for services are considered the patient's responsibility whether insurance pays or not. If your insurance company has not paid your account inf ull within 45 days, the balance will be expected in full.
We will gladly discuss your proposed treatment and answer any questions relationg to your insurance to the best of our ability with the information that we have on file. Please understand:
- Your Insurance plan is a contract between you, your employer, and your insurance carrier. We are NOT a party to that contract.
- Not all services are a covered benefit in all contracts. Some insurance companites arbitrarily select certain services that they will not cover and often times we have no knowledge of this information.
We must emphasize that as dental care providers, our relationship is with you and your child, NOT your insurance company. While the filing of insurance claims is done as a courtesy to our patients, all charges are your responsibility from the date services are rendered.
We will assess a $25 returned check fee. This fee is in addition to the amount of the returned check. If a check is returned, all future payments must be made with cash or credit card. Returned checks and balances older than 30 days will be subject to additional collection fees and interest charges of 1.5% or a minimum or $1 per month. A $60 charge per patient may also be assessed for broken appointments cancelled without 24 hour advanced notice (see scheduling policy).