For your convenience, all financial policy forms are available for print and download below.
Payment For Services:
For your convenience, we accept cash, check, Visa, Mastercard, American Express, Discover, and CareCredit. We deliver the finest care at the most reasonable cost to our patients; therefore, payment is due at the time service is rendered unless other arrangements have been made in advance.
For single tooth extractions, we do require payment in full at the time of service. After payment, we will provide you with a completed claim form to send to your insurance company for reimbursement. For all other procedures, we will be happy to provide an estimate of insurance coverage to you. You will be responsible for your copay at the time of service. Please remember you are fully responsible for all fees charged by our office regardless of insurance coverage.
A 3% discount is extended to our patients who pay their estimated portion in full on the day of the procedure (this does not apply to single tooth extractions.)
We will send you a monthly statement. Most insurance companies will respond in four to six weeks. Any remaining balance after your insurance has paid is your responsibility regardless of our estimated coverage amount given to your prior to your procedure. Your prompt payment is appreciated. Accounts outstanding more than 60 days from treatment will bear interest at 1.5% per month.
Financially Responsible Party Information:
If you are over 18 years of age, you are your own financially responsible party.
If someone other than yourself has power of attorney to make decisions on your behalf, they may be listed as financially responsible.
For children under the age of 18, the parent who accompanies the child to the appointment will be listed as financially responsible for the child regardless of who holds the insurance.
At your consultation appointment, it will be determined if we can offer a payment plan to you. Payment plans are based on a credit evaluation. Patients 18-26 years of age, who are full-time students wishing to use their parent or legal guardian’s credit to qualify for a payment plan may do so with the parent’s signed permission.
We also accept CareCredit which will allow you to make interest free payments if paid within the promotional period.
Failure to pay all charges under this agreement will result in additional collection agency/court fees which typically range from 33-50%.
Please select either the full packet for download or the individual forms needed to be downloaded and printed.
Financial Policy Packet
Authorization to Discuss Protected Health Info.
Financial Policy Guidelines