• Payments are accepted by cash, credit / debit cards, and other cards which function like credit cards such as FSA or HSA cards. We do not accept checks without an already-established history in our office. Checks not honored by your bank (“bounced”) will result in a $50.00 service charge. We also reserve the right to charge the maximum amount allowed by law. Certain treatment plans may also be eligible for payment plans. If qualified, we offer 6 month, no-interest loans through a lender such as CareCredit. For longer term loans credit unions are often a good resource.

• We provide concierge billing services for traditional and most dental PPO insurance plans. As a health-first practice, we aim to remove insurance influence from dental and health outcomes. Thus we maintain an out-of-network status with all insurance plans. We will submit accurate and thorough insurance claims once your treatment is completed with the expectation that your insurance company processes and issues timely payment for covered services. Some insurance plans send reimbursement to our office, some directly to you. This generally takes a few weeks, but occasionally can take longer. However, insurance coverage is never guaranteed. We cannot be held responsible for denied claims for any reason including errors or omissions, lapses of coverage, or ineligibility for services due to frequency limitations, policy exclusions, or any other reason.

• Payment and a card on file is required in advance to reserve appointment time and for all services rendered. We do not bill. However, in the event of a final account balance, we will notify you and require payment with your credit card on file or other pre-arranged methods. Delinquent accounts beyond 7 days are charged a $50.00 late fee. Extended delinquencies beyond 30 days will affect your credit rating and result in legal action.

• You may occasionally have a credit balance and be due a refund. This can happen, for example,
  
 * if you change your mind about treatment after making a payment,
  • if treatment performed was less costly than anticipiated, or
  • if an insurance company paid us directly.
    
    If you have a credit balance you will be notified promptly. Refunds will be made once treatment is complete and a credit balance remains. Refunds cannot be made while there is a debit balance on your account, even if other payments or credits are anticipated. Refunds made against credit card or debit card payments will incur a processing fee of 3% to cover merchant fees. Card refunds can only be made to the original payment card. If the original card is no longer valid, refunds will be issued by bank check. Refunds made against cash payments will be made by either cash or by bank checks at our discretion. Please allow sufficient time for processing.
    
    

• In case of default in payment of any sums of money for services rendered, the patient (legal responsible party) hereby agrees to pay a reasonable attorney fee, late fees, and all court costs incurred by the holder in such action. Said party hereby waives, to the fullest extent permitted by law, diligence, demand, protest, notice of protest, and the benefit of any statute of limitation.

Please initial & sign the Patient Information form to acknowledge and agree to these policies.