Download Printable Version

Financial Policy Form


Insurance co-pay and unpaid benefits: All dental services provided are the direct responsibility of the patient. Our office is happy to file a claim for any patient, whether or not we participate with their insurance. We are participating providers with Delta Dental premier. It is the patient's responsibility to know their insurance plan details. Dental Plan benefits are determined between your employer/group and the insurance company, not your dentist. Your dental policy is a contract between you and your plan company. Your plan and payment is your responsibility. A plan is not a guarantee of payment; it often does no cover all the costs involved in treatment.

The full co-pay and deductible are due the day the services are rendered. If the insurance is denied or the claim has not been paid within 60 days, the patient will be asked to pay the balance in full. Payment in full is due the day of treatment for patients with no insurance. Patients will be notified of credit balances; unless instructed otherwise the credit will be left on the patient's account.

Estimates for treatment: Our office provides estimates for the cost of proposed treatment. The exact amount of benefit paid is determined by the insurance companies and we cannot be responsible for 100% accuracy on any estimate.

In House Membership Plan: We offer an in-house dental membership plan for patients without insurance to be able to receive routine dental care and dental treatment at a discounted rate. This plan cannot be used in addition to an active dental policy to cover copays or deductibles. This plan is strictly for non-insured patients at our practice. In addition, Care Credit cannot be used to cover payments with the in-house membership plan.

Acceptance for treatment: Financial arrangements must be made with this office in order for treatment to begin. Emergency dental services or treatment performed without prior financial arrangements must be paid in cash or by credit card at the time services are rendered.

Missed or broken appointments: The doctor has set aside time specifically for each patient. Therefore, if an appointment is cancelled or missed without a least 24 business hours notice, a fee may be charged to the patient's account. Repeated offenses may result in the patient being dismissed from the practice.

Past due accounts: We reserve the right to impose a 1 ½ % monthly service charge (18% annually) on the unpaid portion of balances over 30 days past due.

Accounts sent to collections: Any balance more than 90 days past due may be sent to a collection agency. Any collection agency and/or attorney fees will be charged to the account holder.

Returned checks: Any checks returned unpaid will incur a fee as well as the original amount of the check. The account will then need to be paid by cash, credit card, cashier's check or money order.

By signing below, you are stating that "I understood and accepted the policies listed above. I grant permission to be contacted by phone at home or work to discuss matters listed above."


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.