Payment for Services Rendered:
Payment for services rendered is due at the time the services are provided. If you have provided us with current insurance information, your signature below authorizes us to submit a claim to that insurance company for payment. It is not the responsibility of this office to negotiate with your insurance company regarding your coverage or denial of a claim. Coverage of services including estimates are not guaranteed. Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is your responsibility. By signing below, you are acknowledging that any and all fees that are not covered or paid by your insurance company remain your responsibility and should be paid within thirty (30) days. You are further acknowledging that you understand that it is our office policy that accounts that remain past due may be subject to a collection fee.
Broken Appointments:
We require at least a twenty-four (24) hour notice for the cancellation of any appointment. Appointments cancelled within 24 hours of their scheduled time will result in the assessment of a $50.00 cancellation fee.
Our practice is committed to the success of your dental treatment and want to provide you with the best service available. We welcome you to ask questions and to be involved in the understanding of our financial policy.
