Office Policies and Financial Responsibilities
PAYMENTS are due at the time of treatment. For your convenience, we offer the following payment arrangements: Cash, Personal Checks, Money Orders, Visa, MasterCard, American Express, Discover, Care Credit and Citi Health Card. A RETURNED CHECK FEE OF $35.00 will be charged to any account for any check returned for insufficient funds
INSURANCE claims are filed for you as a courtesy. Dental insurance is a contract between you and your insurance carrier. Our goal is to help you maximize insurance benefits available, so we can assist you in making excellent dentistry affordable. We base our ESTIMATES on the information we receive from your insurance plan. You will responsible for the ESTIMATED patient part plus a deductible, if applicable , at the time of service. If there are any changes in your plan or coverage, it is your responsibility to provide the information PRIOR to being seen. If for any reason any claim is denied / and or unpaid the patient/guarantor is responsible for those charges.
CANCELLATIONS are a pain for everyone. Please understand we have reserved appointment time just for you. We schedule hygiene appointments up to 6 months in advance. We highly recommend this to assure you get an appointment time that will meet your scheduling needs. We realize on occasion, that things may arise to keep you away. We ask that you notify us as soon as possible, but no later than 24hours in advance of the appointment to avoid a $25 charge to your account.
DELINQUENT ACCOUNTS will be subject to collection activities and all information will be sent to all major CREDIT AGENCIES. You will be responsible for all fees and charges applicable by law. Any account overdue by 30 days will receive a monthly billing fee, UNLESS OTHER PAYMENT ARRANGEMENTS HAVE BEEN MADE.
I certify that I am the patient or authorized general agent of the patient. I have read and fully understand my financial responsibilities under this policy.