About

​Financial Agreement

 

We are committed to providing you with the highest quality dental care. Clear communication about financial
expectations helps us keep our focus on your health and comfort. Please review and sign the following agreement
regarding financial responsibility.

Insurance
• As a courtesy, we will verify your benefits and file insurance claims on your behalf.
• Your insurance policy is a contract between you and your insurance carrier. You are responsible for all charges not
covered by your plan.
• Any estimate of coverage provided by our office is not a guarantee of payment. Final determination is made by your insurance company after the claim is processed.
• If your insurance has not paid within 45 days from date of service, the balance will become your responsibility.
 

Payment Options
• Payment is due at the time of service unless prior arrangements have been made.
• We accept: cash, checks, major credit cards, and most HSA/FSA cards.
• For treatment plans over $500, payment plans may be available through third-party financing (e.g., CareCredit) but patient will be responsible for establishing financing through these companies.

Patient Responsibility
• Patients without insurance are expected to pay in full on the day of service.
• Co-payments, deductibles, and estimated patient portions are due at each appointment.
• Balances not paid within 90 days are subject to a 1.5% monthly finance charge (18% APR).

Deposits for Major Treatment
• A $100 deposit is required when scheduling treatment totaling $1,000 or more.
• This deposit will be applied toward your treatment.
• If you cancel or miss the appointment with less than 48 hours’ notice, the deposit will be forfeited as a no-show fee.