NEW PATIENT FORMS
• Notice of Privacy Practices
New Patient Forms:
Please print and sign the following documents for your first appointment:
• Patient Registration
• Dental History
• Medical History
• Financial Policy
• Receipt Acknowledgement of Notice of Privacy Practices
5% discount for payment at time of service. Cash, Check, Visa, MasterCard, American Express or Discover Card are accepted.
We also accept monthly payment plans through Care Credit, a line of credit to be used for health care costs. Apply online at carecredit.com. An approval may take less than 15 minutes.
• NO INTEREST Payment Plans
• Convenient, low monthly payment plans
• No annual fees or pre-payment penalties
For those patients with dental insurance we will assist you by filing your claim for procedures completed in our office. The difference between the insurance benefit and our fee for treatment is subject to the payment options described above.
We will perform an initial insurance verification and do our best to provide you an estimate of your co-pay prior to your appointment. If you are covered by two insurance companies, you need to be aware of a “Duplication Clause” and verify whether your secondary insurance has standard coordination of benefits. This may limit your secondary insurance payment. Be aware of your insurance benefits, exclusions and frequency limitations. Every plan is different and changes do occur frequently.
All incurred charges are ultimately the responsibility of the patient regardless of insurance coverage and are due within 45 days of service.
Any balance over 60 days old will be subject to 2.0% monthly finance charge. Returned checks for insufficient funds or closed accounts are subject to a $35.00 fee. If a check is returned, cash or credit card will be the only accepted form of payment. A fee of $50 is charged for patients who miss or cancel more than 1 time in a calendar year without 24-hour notice. If a collection agency becomes involved in the settlement of your account, all collection costs and legal fees for both parties are the responsibility of the account holder.