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Financial Policy Form

PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF SERVICE

As a favor to you, we will file your insurance claims. Please note that it is the responsibility of the patient to inform us of any change in your employer or insurance coverage.

If you have dental insurance, you will be required to pay your deductible and ESTIMATED PORTION of the fee, if any, at the start of service. You will also be responsible for any balance remaining after your insurance company has paid on your claim, since their ESTIMATES of coverage are not a guarantee of payment, but merely an estimate over which we have no control.

While the filing of insurance claims is a courtesy that we extend to our patients, we must emphasize that as dental care providers our relationship is with the patient, NOT the insurance company. If we do not receive payment from your insurance company within a reasonable amount of time (60) days, the balance will become your responsibility. A monthly interest charge of 1.50% will be charged after 60 days.

A fee of $40.00 will be charged for any appointment cancelled without 24 hours notice.

A fee of $25.00 will be charged for any returned checks.

In an effort to provide you with flexible payment arrangements, we have expanded our payment policy.

PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT

We now offer the following payment options:

Please make your choice, sign below and return to office manager before treatment.

Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance. You may also choose a comfortable amount to be automatically billed to your Visa or MasterCard on a monthly basis.

If none of the above options apply, please see the office manager. Thank you

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.
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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.

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