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Financial PolicyThank you for choosing us as your dental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy that we require that you read and sign prior to any treatment.PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE.WE ACCEPT CASH, CHECK AND MOST CREDIT CARDS.PAYMENT PLANS ARE OFFERED ON APPROVED CREDIT.WE ALSO ACCEPT AND OFFER CARE CREDIT.REGARDING INSURANCE AND PATIENT PAYMENTWe are happy, as a courtesy to our patients, to bill your insurance company on your behalf. We will do everything reasonable to ensure that you receive the maximum benefit from your insurance plan. To do this, we require that you bring in and complete all your insurance information and, where required, provide us a signed company of your insurance’s claim form. Please be aware that your insurance policy is a contract between you and your insurance company. We are not a party to that contract. We provide care to you, not to the insurance company. Thus, the entire balance is your responsibility, regardless of whether or not your insurance company pays us.We will accept assignment of benefits from your insurance, if you authorize payments to be made to us. However, any deductible or patient portion must be paid in full at time of service. Because you are responsible for the entire balance, if your insurance company has not paid your account in full within 60 days, you agree to pay in full the balance of your account. You also agree to a 1.5% monthly (18% annual) service charge on balances overdue past 60 days. Please be aware that we cannot guarantee what insurance will pay since we are not their agents, and that some and perhaps all of the services provided may be “non-covered” services and not considered reasonable and necessary under some insurance plans. ADULT PATIENTSAdult patients are responsible for full payment at time of service.MINORSThe adult accompanying a minor and the parents (or guardians) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, paid with credit card, cash or check is made at time of service.MISSED APPOINTMENTSUnless cancelled at least 24 hours in advance, our policy is to charge $25.00 for missed appointments. Please help us serve you better by keeping scheduled appointments.Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.I have read the Financial Policy (above) completely. I understand and agree to this Financial Policy: Signature- Patient or Responsible PartyDate ................
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