Financial Info
![]() Dental insurance: As a courtesy we will gladly file your claims and accept assignment of benefits provided you agree to the following:
MINOR PATIENTS: The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at the time of visit. RETURNED CHECKS: A charge of $35.00 is applied to your account when a check is returned by the bank. Financial Agreement FINANCE CHARGES AND COLLECTION FEES: Financial charges will be applied to all balances not paid within 30 days of the service date. A late charge of $20.00 on the balance unpaid and owed will be assessed each month until the bill is paid. It is your responsibility to ensure your insurance company pays promptly so you can avoid late charges. You agree to pay collection cost and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. We understand temporary financial problems may affect timely payment of your balance. In those situations we encourage you to communicate any such problems immediately so we may assist you in the management of your account. OVERDUE BALANCE: An account with an unpaid balance past 90 days will be sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees, and any fees associated with the collection of your debt. BROKEN (LATE OR MISSED) APPOINTMENTS: Appointments not kept or changed with less than 48 hours notice are considered broken. Broken appointments will be rescheduled during the morning hours and subject to additional fees. Broken appointments prevent others from receiving the dental care they deserve. We take them very seriously so please be considerate and inform us in advance if you need to change your appointment. FEE FOR MISSED APPOINTMENT IF 48-HOURS NOTICE GIVEN: To reschedule or cancel an appointment, you must notify us at lease forty-eight (48 hours) in advance to avoid a missed appointment fee of up to $35.00. We reserved the right to terminate professional treatment of any patient when scheduled appointments are not kept. RECORDS AND REIMBURSEMENTS: Original records are the property of this office. If you desire we will provide you a copy of your child’s record or radiograph for a nominal duplication of fee. SPACE MAINTAINERS AND OTHER APPLIANCES: All appliances must be delivered within 30 days from the time of impression to ensure a proper fit. If an appliance is delivered after 30 days and does not fit, you will be responsible for an additional fee to remake the appliance. Also, if the appliance is broken or lost by your child you will be responsible for the additional fee to remake it. |