Payment is due at the time of service.
Payments may be made by cash, check, Visa, MasterCard, American Express, Discover and CareCredit.
- A service charge of $25 will be assessed by our office on all returned checks, in addition to any bank service charge.
- Proof of identification is required on all payments by check.
- Third party checks are not accepted.
New patient emergency visits must be paid in full at the time of service.
Insurance assignment and management:
- Patients must provide our office with accurate insurance billing information at the time of appointment.
- We may require advance submission of insurance claim for any work to be performed. In such circumstance, a treatment plan will be arranged prior to service.
- Patients are responsible for all charges, co-pay, etc. not covered by their insurance plans together with all fees in excess of the insurance carriers' usual and customary fee schedule.
- Our office will submit a claim to your insurance provider on your behalf to secure payment. For each instance we shall attempt a maximum of two insurance submissions. Further insurance appeals become the patient responsibility.
- Our office will accept assignment for only the primary insurance provider. Secondary coverage will be paid to the patient. We are happy to process secondary claims for patient reimbursement.
In all cases, account balances remain the patients responsibility. Patients are responsible for balances in full after 60 days regardless of any third party responsibility (eg., Insurance provider, court assigned responsibility, private third party payer, etc).
Statements are sent out at the end of each month. Balances due are payable upon receipt. Patient balances remaining delinquent after 60 days will be turned over to collection.
We reserve the right to require advance cash payment in the event of future series to patients with delinquent accounts.
I have reviewed the above financial policy and agree to the terms and conditions contained herein.