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Thank you for choosing our practice as your healthcare provider. Our office is dedicated to providing optimal care for every patient in the most economical way possible. The following is a statement of our financial policy. Please read it and let us know if you have any questions. We feel misunderstandings can be avoided when complete information is exchanged.

OPTIONS FOR PAYMENT OF TREATMENT:

1. Non-Insurance Patients:

Payment is expected at the time of service for treatment performed that day unless prior arrangements have been made. For your convenience, we accept Cash, American Express, Mastercard, Visa and CareCredit.

2. Insurance Policy:

a. We will file an insurance claim on your behalf as a courtesy to you however, you must supply, prior to

treatment, all the necessary information for filing.

b. Any deductible as well as any estimated percentages your insurance does not cover, are to be paid on the date of

the treatment.

c. It is the patient’s responsibility to know the details of the insurance coverage, including percentages

payable, waiting periods, deductibles, yearly maximums, services not covered under the plan, and any other related information.

d. If your insurance company has not paid their liability in full within 60 days, the balance then becomes the

patient’s liability.

e. For patients whose insurance company pays them directly, payment is expected on the date of the treatment.

f. Your insurance policy is a contract between you and your insurance company and the financial

responsibility for your treatment is yours whether the insurance company pays or not.

3. Finance charges of 1.5 % per month will be applied to balances over 60 days old.

4. Long term payments may be available. We have information on several companies that offer this service and we can help

you with the details. (This would allow you to make monthly payments, spreading those payments over a desired period of time.)

Again, please feel free to ask any questions that may be regarding this policy. We are most willing to help you in any way that we can.

I HAVE READ THIS FINANCIAL POLICY AND UNDERSTAND AND AGREE TO THE TERMS OF THIS POLICY.