OFFICE POLICIES: Insurance / Payment / Office Appointments

We would like to acquaint you with our Office Policies. We encourage all of our patients to
take responsibility in understanding their dental coverage as dental insurance is a contract between
you and your employer. With all of the frequent changes in contracts, policies, and guidelines, it is
not possible for us to keep track of all these changes to insurance plans and requirements so please
contact your employer and know your specific plan.

Our goal is to help you achieve and maintain optimal dental care and provide a good doctor-
patient relationship. Letting you know of our Office Policy in advance allows for a good flow of
communication and enables us to achieve our goal. Please read this carefully and if you have any
questions please do not hesitate to ask a member of our staff.

Upon arrival, please check in at the front desk and let us know of any changes in your dental coverage,
your place of residence, or phone numbers.

Please let us know if you have any questions. It will be our pleasure to help you.

Insurance Policy

• According to your insurance plan, you are responsible for all deductibles and co-insurances.
• Some insurance plans only allow one dental cleaning every six months, other plans allow for
  2 cleanings each year. Please check with your insurance company of your policy’s frequency
  limitations and schedule accordingly.
• Not all services provided by our office are covered by every plan. Any services determined not
  covered by your plan will be your responsibility.
• We do not want to compromise your care based on restraints placed by an insurance company.
  So, please tell us if you need to know in advance what your coverage is. We will be happy to
  provide an estimate of your out-of-pocket responsibility prior to your appointment.

Payment Policy

• Patient balances are billed immediately upon our receipt of the insurance company’s
  explanation of benefits. Your remittance is due within 60 days of your receipt of the bill.
• If previous arrangements have not been made with our billing office, any account with an
  outstanding balance greater than 60 days will be charged 1.5% finance charges will be applied
  after 60 days.
• If you have no insurance, payment is due at the time of service unless previous arrangements
  are made with our billing office.
• If you have an insurance that reimburses you directly, we will submit all the paperwork for you,
  but payment is due at the time of service unless previous arrangements are made with our
  billing office.
• For your convenience, we work with an outside Financial Company, CARE CREDIT, (click to
  apply now) that offers very attractive options for extended payments. They even have a 12
  month interest-free plan.

Cancellation Policy

• We would appreciate 24 hours notice for canceling any appointments. A fee of $81.00 will be
  charged for any broken appointments, or any appointments canceled with less than 24 hours.
• Patients that accumulate a total of 3 NO SHOWS/SAME DAY CANCELATIONS in a calendar
  year will automatically be terminated from our practice as a patient.

Office Policy

• A written request is needed for transferring dental records.
• Our office remains dedicated to providing optimal care for every patient and working with you
  to achieve that goal. We pride ourselves on helping you in any way we can to provide the quality
  of care to which you have become accustomed.