A Word About Our Payment Policy

We make every effort to keep down the cost of your care. You can help by paying in full after each visit. You may request an estimate of the charges for any procedure or surgery.

We feel that everyone benefits when there is a definite and clear financial agreement prior to treatment. To make your financial arrangement as easy as possible, we accept the following methods of payment: Cash, Check, Visa, MasterCard, American Express, and Discover.

Option 1. Payment in full is due the day of treatment.

Option 2. Divided payments (for amounts over $800) of up to four equal payments can be arranged by automatic billing on your credit card. First payment is due on the day of treatment. (This option is for those patients who are not utilizing any insurance.)

Option 3. Insurance claims will be submitted to participating companies for all covered services. Your deductible and copay, if any, will be due and collected at the time of service. No payment arrangements may be used with this option.

We will be happy to file your insurance as a courtesy; however, any balance still due after 90 days will become the patient’s responsibility. Any balance still due after 120 days will be charged a finance charge (1%) per month until paid in full. Your insurance is a contract between you, your employer, and the insurance company. It is the patient’s responsibility to know their insurance benefits and to make sure that any claims are paid within a timely manner. Any procedure not covered by a patient’s insurance will be the responsibility of the patient. This will include any procedure that their insurance denies as medically or dentally unnecessary. By signing this form, the patient agrees to these terms.

Self-pay patients, or patients not utilizing insurance coverage, with balances over $1,500 and making full payment on the day of service, will receive a 5% discount. (Cash, Check, and Credit all apply)

In the event of a returned check, there will be a $20 fee charged to that patient’s account, and the account must be paid in full within 10 days to avoid further collection activity. If an account is turned over to an attorney or collection agency, the patient/parent/guardian is responsible for all reasonable attorney and/or collection agency fees that may be charged in addition to their balance due.

Download the Payment Policy form here before your appointment. Please sign and date it, and bring it with you to your appointment.

Download the Payment Policy form