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Financial Policy Form

This statement is to inform you of our financial policy. Our office is committed to providing you with the highest quality dental care using only the best materials and technology in dentistry today. We are also committed to providing you up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. Our financial policy is designed to facilitate excellent service while minimizing our administrative costs.

INSURANCE

All charges you incur are your responsibility regardless of any insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient not with your insurance company. Our office is not privileged to their contract or payment schedule.

As a courtesy to you, we will help you process all your insurance claims. We will submit the appropriate attachments, such as x-rays, periodontal charting or narrations. In order for our office to file your insurance claims you must provide us accurate insurance information before any dental treatment is performed, as we are not responsible for problems created by incorrect insurance information.

PAYMENT

Payment is due at the time service is provided. Our office accepts CASH, PERSONAL CHECKS, CREDIT CARDS. Returned checks will be subject to a service charge depending on bank charges. Finance charges incur at the rate of 1.8% per month (21.6% annually) on balances over 30 days old. For specific situations we will permit some payments to extend over the 30 day period, with balance paid in full.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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