Statement of office Policy and Patient Responsibility

Once an appointment has been made it is your responsibility to keep that appointment. Please remember that time has been reserved for you. There is a minimum charge of $50.00 for each broken appointment with les than a 48-hour notice.

We are happy to file the necessary claim forms to assist you in receiving the full benefit of your coverage. However, we cannot guarantee any estimated coverage. Because the insurance company policy is an agreement between you and the insurance company, (Patients are ultimately responsible for all charges). If for some reason your insurance carrier does not pay the balance in full, we will send you a statement for the remaining balance. Often, you will receive an Explanation of Benefits (EOB) from your insurance company showing what is paid and what your responsibility is. IF YOUR INSURANCE COMPANY MAILS YOU THE PAYMENT FOR SERVICES RENDERED IN OUR OFFICE, YOU ARE RESPONSIBLE FOR MAILING OR BRINGING THAT PAYMENT INTO OUR OFFICE TO SETTLE YOUR ACCOUNT BALANCE.


Cash: We are happy to offer a 5% pre-payment courtesy for all treatment
Paid in full 3 days prior to treatment. ($500 minimum, cash or credit)
Credit Cards: For your convenience we have made arrangement to accept payments by several major credit cards. Please verify with the Patient Care Coordinator, before treatment, that we accept the type of credit you intend to use.
Payment Arrangement: Unfortunately, the office is limited in its ability to make extended
Payment arrangements. However, in an effort to meet the needs of our patients, we are now associated with “Dental Fee Plan” Please ask the Patient Care Coordinator for details.

After 60 days all delinquent accounts will be referred to a collection agency and the patient or guarantor of the account will be responsible for all collection fees, court costs and attorney fees associated with the collection of the account. A $50.00 return check fee will be assessed on all returned checks.

On occasion an insurance carrier may provide a benefit for a procedure, which based on our records, was not a covered benefit, which you already paid. In such instances an audit of your account will occur. If in fact our records support this, a credit will be given towards your next treatment.