Patient Financial Policy Form

• As our patient you are ultimately responsible for all charges associated with your treatment, regardless of insurance. We will ask for payment at the time of service.
• All patients who are seen in our office for a comprehensive exam will be provided with a treatment plan. This is the estimated cost of your dental treatment. It may also include an estimated insurance payment based on your plan’s coverage.
• Payment is due at the time services are rendered. Our office accepts payments by cash, checks, Visa, MasterCard and Discover credit cards.
• We are always happy to assist you with any questions you have regarding your account.
• Emergency patients should expect to pay at the time of service.
• Any deductible and / or co-payment will be due at the time of service.
• If you have multiple insurance coverage, it is your responsibility to let our office know which is primary and secondary.
• Our practice does not participate in state or federal assistance such as Medicaid - Medicare-Dr Dynasaur programs.
• Parent(s) or Guardian(s) accompanying a minor are responsible for providing accurate insurance information & are financially responsible for any balances due at the time of services. If they can’t YOU MUST CONTACT US TO PLAN PRIOR TO MINOR’S APPOINTMENT.
• If payment for services rendered has not been paid in full within 60 days either by you or your insurance, the remaining balance for your treatment is considered due and must be paid by you.
• Please be advised that any delinquent accounts are sent to collections after three (3) payment reminder letters. The 4th letter will be a collection warning letter with a final due date.

Affordable Financing Options

We strive to provide you with affordable, high-quality treatment that fits your budget. Your treatment plan will include a breakdown of all applicable fees, and we will inform you of all costs before treatment is administered.

Don’t let finances stand in your way for achieving the beautiful, healthy smile you deserve! We are pleased to offer two payment options CHERRY and CareCredit that offer patients the ability to get quality dental care by paying overtime through equal monthly payments so you can focus on what matters most – keeping your smile healthy!