Financial Agreement
You, the patient or guardian of a minor, are responsible for the full cost of all treatment provided. Payment is due on the day services are provided, at the time of your appointment. Copayments are always an estimate and not a guarantee of your out-of-pocket expense. Insurance providers do not guarantee coverage for service. Pretreatment estimates issued by your insurance provider are not a guarantee of payment. Copayments estimated in-office and discussed prior to treatment or on the day of service are always an estimate and never a guarantee of your out-of-pocket expense. Any balance remaining after your insurance claim has been processed is a balance owed by you.
As a courtesy we will process your insurance claims. You, the patient or guardian of a minor, are solely responsible for your insurance policy. You are responsible for providing the office with your current insurance information at every visit. You are subject to your insurance provider’s maximum, deductible, guidelines, and network restrictions. For questions regarding your insurance network, maximum, policies, guidelines, or remittance grievances contact your insurance provider.
Balances remaining after your insurance has processed are owed by you and due within 30 days of your first billing statement. Accounts over 30 days are subject to a finance charge of 1.5%. Balances over 180 days will be sent to collections.
We accept cash, check, MasterCard, Visa, Discover and American Express.
As a courtesy we will process your insurance claims. You, the patient or guardian of a minor, are solely responsible for your insurance policy. You are responsible for providing the office with your current insurance information at every visit. You are subject to your insurance provider’s maximum, deductible, guidelines, and network restrictions. For questions regarding your insurance network, maximum, policies, guidelines, or remittance grievances contact your insurance provider.
Balances remaining after your insurance has processed are owed by you and due within 30 days of your first billing statement. Accounts over 30 days are subject to a finance charge of 1.5%. Balances over 180 days will be sent to collections.
We accept cash, check, MasterCard, Visa, Discover and American Express.
