Payment for all services are due at the time services are rendered. 

We accept the following payment types: 

CASH/CHECK- This includes money orders. A $35.00 service charge will be added to accounts for returned checks. Two (2) returned checks on your account will require future payments to be made by cash or credit card. 

ALL MAJOR CREDIT CARDS – We also accept any flex spending account cards. 

CARECREDIT – A separate line of credit offered through Synchrony Bank to cover your entire family’s dental needs. If approved, there are options available with no interest if paid in full during the promotional period. 

All unpaid balances over 60 days will be subject to collection procedures including a collection fee of 40% of the balance on your account and 2% interest per month (24% APR). If we go to small claims court, you will be subject to collection fees, reasonable attorney fees, and court costs. 

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. However, you must realize: 

Your insurance is a contract between you, your broker/employer, and the insurance company. We are not a party to that contract. It is your responsibility to be aware of your insurance status, annual maximums, deductibles, and exclusions/clauses. 

Our fees are generally considered to fall within the usual and customary range by most companies, and therefore, are covered up to the maximum allowance determined by each carrier. This only applied to companies who pay based on a percentage (ex. 100, 80, 50) of the usual and customary/reasonable fees. This does not apply to companies who reimburse on “schedule” of fees, which bears no relationship to the current standard and cost of care in this area. 

Not all services are a covered benefit in a contract. Some insurance companies select certain procedures they will not cover regardless of medical/dental necessity. It is your responsibility to know what they will and will not cover. 

While filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility and are to be paid in full within 60 days of your last billing statement. If insurance has not paid within this time, it is your responsibility to contact them and obtain status. 

Please be aware that you need to give 24 business hour notice to cancel your appointment. If not, the appointment is considered broken. There will be a $50 broken appointment fee charged to your account. If you are more than 15 minutes late for your appointment, the appointment is considered broken. Three broken appointments and we will be unable to schedule you any further appointments. 

If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help! 

Signature of Patient or Legal Guardian:

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Date:

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