Office Financial and Insurance Policy

model of a tooth with exposed root and carved pumpkin with a face

Our fees are meant to be fair and reasonable.

We strive to keep them that way. You assist that effort when you pay for our services at the end of each visit.

As you are aware, new patients and those requiring emergency care are expected to make full payment at the time of their appointment.

Our staff can tell you the approximate fee for treatment before your appointment. To make payments convenient for you, we accept cash, personal and business checks, Visa, MasterCard and Discovery credit cards.

We cooperate fully with all our patients who are covered by insurance plans. We are also a participating office in a limited number of Preferred Provider insurance plans with assignment. Please check with our staff before treatment to determine if yours is one of the plans. We expect insured patients to read their policy carefully, to become familiar with its benefits and limitations, and to bring a copy of the policy brochure to our office.

It is important that you understand that in most cases your insurance is designed to reduce your cost, NOT to eliminate it completely. You are ultimately responsible for the full amount of your bill, regardless of your insurance coverage.

Established patients having insurance are expected to pay their deductible and co-payment percentage at the time of service. Any difference will be billed after the insurance payment has been received.

As a courtesy, we will always submit the insurance claim for the you, even if we do not participate with the insurance company. It is important that you understand that most insurance companies will reimburse the dental office even if we do not participate. In this case, you will be responsible for your deductible and co-payment. However, there are a few plans (listed here) that send the check directly to you. In this case, you are responsible for payment in full at the time of service.

Any insurance payment not received after forty-five (45) days of filing becomes the responsibility of the patient. Payment from the patient is expected within ten (10) days of notification.

If an account is outstanding for more than sixty (60) days, a monthly service charge of 1.5% (18% per year) will be added to the balance. If the account is not cleared within the time specified, the account will be turned over to our collection service and a 15% collection fee will be added.

Any checks returned to our office are subject to an additional fee of $25.00. Immediate remittance in the form of cash, money order, credit cards or certified funds is expected.

If, at any time, you have a question about this policy or your account, please do not hesitate to contact a member of our staff for assistance.

I have read the above policy and agree to accept all financial responsibility for:





Signature (Relationship
to Patient)
authorize the release of any information
necessary to process my dental claim.

do assign insurance benefitsI

do not assign insurance benefits



Signature Signature

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If you’re in need of general & cosmetic dentistry, contact us today to schedule an appointment!

Call us: (410) 551-4600