Financial Obligation Form ← Click here to download the form
(Please print this form, review the policy and bring your copy to the office)
Our office has established procedures that maintain quality care and reasonable cost for our patients. Fees for your consultation and x-ray interpretation are due at your first appointment. We will be happy to discuss these terms and financial arrangements for your treatment with you during your visit. You will be given a detailed estimate of the surgery treatment fees after the consultation appointment. The fees quoted are an estimate only. If the procedure proves to be more complex than anticipated, the fees will be adjusted accordingly. The stated fees will be honored for a period of 90 days. Since we want to keep our fees as low as possible, payment on the day of treatment is required. For your convenience, we accept cash, personal checks, VISA, MasterCard, American Express, and Discover. We also offer a medical and dental charge card, for which you can apply at the time of your visit. Care Credit allows easier payment for charges that are above and beyond or not covered by your insurance plan.
Your insurance coverage
Insurance is in place to help assist you in the cost associated with your recommended treatment. Insurance rarely covers the entire cost of the treatment. Therefore, your insurance should be viewed as a supplement that helps to defray the cost of your care. The patient is therefore responsible for the remainder of the fees associated with their treatment. Please be aware that each dental plan independently determines the maximum fee allowance for each type of service. If you have insurance, we will calculate your estimated insurance coverage and patient portion at the time of surgery. Your patient portion is due at the time of surgery. You will be responsible for any balance remaining after the insurance company processes your claim. Upon receipt of your company’s dental plan payment, we will refund any credit or bill the balance to you. We will assist you in properly filing your claim. You must understand that insurance coverage is a contract between you and the insurance company – not between the insurance company and the doctor. Our services are provided to you, the patient, and not to your dental plan. The financial obligation between you and our office is not dependent on insurance coverage. We will assist you with filing your claim. We will also monitor your claim to help assure that you receive the maximum benefit from your dental or medical plan. The ultimate responsibility for the payment of your account is with you, not the insurance plan.