We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policy.

Payment for services is due at the time services are rendered unless payment arrangements have been approve din advance by our staff. We accept cash, check, Master Card, Visa and Discover. We will gladly assist you by sub bitting all insurance claims pertaining to charges for care rendered in our office. Returned checks and balances older than 30 days may be subject to additional collection fees of $30 per month.

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.

2. When our office calls to verify estimated insurance benefits or sends in written pre-authorization, the insurance company will always have a disclaimer that there is no guarantee of benefits. Insurance companies have the liberty to charge your benefit structure at any giving time without notifying our office.

3. Not all services are a converted benefit in all contracts. She insurance companies arbitrarily select certain services they will not cover. Your orthodontic benefits may tie in with your dental benefits, making it impossible for us to get an estimated benefit.

We must emphasize that as a dental care provider, our relationship is with our patients and their families and not with their respective insurance companies. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are you responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about ehe above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you!

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.

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