Thank You for selecting us as your dental health care provider. The following 
information describes our Financial Policy. Our primary goal is that you receive the optimal 
treatments needed to restore and maintain your dental health. In order for us to continue being 
able to provide these treatments, financial flow is a practical necessity. Therefore, we ask you to 
review this information and if you have any questions or concerns about our financial policies, 
please do not hesitate to ask one of our office managers.
Payment for services is due at the time services are rendered.
We accept cash, personal checks, 
and for your convenience AmericanExpress, MasterCard, Discover, and Visa.
We have an agreement with 
 to offer interest free financing for our patients.
We will help you process your insurance claim for your reimbursement as long as we have complete 
insurance information. It would be time efficient if you bring this information before or at the
time of your visit. In special instances, we accept assignment of insurance benefits.
1. We ask that you keep in mind the fact that your insurance policy is a benefit to you and a 
contract between you, your employer, and the insurance company. Due to the fact that we are not 
a party to that contract, our financial relationship is and will remain with you, not your insurance 
2. All charges are your responsibility whether or not your insurance company participates. Not 
all services are covered benefits in all contracts. Some insurance companies arbitrarily 
select certain services they will not cover.
3. Fees for these services, along with unpaid deductibles and co-payments are due at the time 
of treatment.
4. If the insurance company does not pay your balance in full within 30 days, we will ask 
that you contact the carrier to help speed things up.
5. If the insurance company does not pay in full within 45 days, we will require you to pay the 
balance due.
6. Balances older than 90 days may be subject to additional collection fees and interest 
charges of 1.42% per month. These added fees will become your responsibility, so all efforts will 
be made not to reach that 90 day mark. In the unfortunate event of a returned check, an 
additional fee of $35.00 will be added to the amount of the returned check.
We understand that temporary financial problems may affect timely payment of your balance. 
We encourage you to communicate any such problems to us so that we can assist you in the 
management of your account.