Payment Policy

Use the form below to submit your Payment Policy Agreement.

Payment Policy

Use the form below to submit your Payment Policy Agreement.

  • Payment Policy

    In an effort to control fees, we recognize that one of the best methods is to control costs. We have therefore instituted the following policies as an aid in controlling bookkeeping overhead expenses. For those patients who do not have dental insurance, payment in full is expected for services rendered on the day of service, unless prior financial arrangements have been made. If the patient or responsible party has an insurance program, the office will produce and send claims to the insurance carrier (usually within 24 hours of the appointment), provided evidence of benefits (insurance card, employment verification) is presented to the office. Any portion of services not covered by insurance is due on the day services are rendered unless prior financial arrangements are made. The office will not be responsible for follow-up delayed insurance payments or for negotiation of any settlements on any disputed insurance claims regarding any services rendered by the office. When there is a delay in receiving payments from the insurance carrier, it is the responsibility of the patient or responsible party to investigate the delay. The responsible party will be requested to make payment in full when an insurance claim is delayed beyond 45 days of the date of service. If it is necessary to change your reserved appointment time, we request notification of at least 24 hours in advance of the appointment during business hours or by leaving a message on our answering machine after hours. Failure to keep a scheduled appointment or provide appropriate notification will result in a charge of $30.00. If you have any questions we will gladly try to answer them for you.
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    By signing below, I agree to the payment policy terms.
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