Dear Patient,
Thank you for choosing us to provide you and your family with the best dental care possible. As a part of our service
to you, we make every effort to contain the ever-rising cost of dental care. In order to do so, this Financial Policy
shares cost containment responsibility among our patients. Please read this policy carefully, sign, date and return it to
the front desk. If you have any questions regarding such policy, please let us know.
Cancellations must be on a business day within 48 hours prior to your appointment or your account will be charged $50.00 per hour scheduled.
We do accept assignment of benefits. However, we do require you pay your portion at the time services are rendered. On AVERAGE a patient’s copay is as follows:
Preventive Services: 0% - 50% (routine cleanings, dental exam, x-rays)
Basic Services: 20% - 50% (restorative, endodontics, periodontics)
Major Services: 40% - 50% (crown(s), bridge, partial/full dentures)
*Deductibles and annual maximums may apply and will vary from policy to policy.
We will bill your insurance company for services rendered. If your insurance company has not paid the
balance within 60 days, the balance on your account is your responsibility and must be paid in full.
If an insurance claim is denied, as a courtesy our office will resubmit once with the requested information. If
there are continued denials, it is the insured’s responsibility to follow up with the insurance company.
Our practice is committed to providing you with excellent treatment and our fees are reflective of the rates of
comparative providers in the area. These fees will be discussed in advance of any treatment and are your
responsibility regardless of your insurance company’s determination of “usual and customary” rates.
We accept Visa, MasterCard, Discover, American-Express or Cash. Also, added for your convenience we have
financing available through Care Credit. Please see the front desk for additional information on this option.
Thank you for your cooperation in this matter. We are looking forward to serving all of your dental needs.
