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We are committed to the highest level of quality in oral rehabilitation. Please understand that payment for services rendered is part of your treatment. Outlined below is our financial policy. Please read it carefully and sign it before being seen by the doctor. Payment is due at time of service. We accept cash, checks, Visa / MasterCard, and American Express. If you have dental insurance, you are expected to pay your estimated portion, all co-pays, or deductibles at the time of service. Most dental insurances do not cover any portion of implant reconstructive procedures. With prior arrangements, we may offer extended payment plans. Our practice is committed to providing the best treatment for our patients. This is based on a diagnosis indicating the treatment needed to save your teeth or to prevent further loss or damage to your gums or teeth. The treatment we recommend can not be based on what your insurance policy will cover, the amount of money you have left on your deductible, or how economical the treatment will be. It will always be based on what is in the best interest of your oral and dental health. Regardless of any insurance company s arbitrary determination of what  usual and  customary is, you as the patient are ultimately responsible for payment. We may accept assignment of insurance benefits after your second visit. You will still be expected to pay the full fee for treatment. You will be refunded whatever portion your insurance carrier contributes. The actual amount could vary, depending on what your insurance will cover, or unexpected changes of treatment. You are ultimately responsible for any balance for services rendered. We cannot bill your insurance company unless you give us your insurance information and an original claim form. This information must be provided and filled out accurately before treatment begins. Your insurance policy is a contract between you and your insurance company. We are not a party to that agreement. If financial arrangements are made for an extended payment plan, we ask you to adhere to this agreement. A 1.5% finance charge (18% annually) will be added to your balance that is more than 60 days overdue. To prevent finance or rebilling charges, we ask that you comply with your original financial agreement. If your account becomes delinquent for more than 60 days and you are in need of additional treatment, full payment must be made prior to the time of service. Patient ___________________________________ Date______________________ Parent or Guardian _________________________ Relationship _______________ Your Name D.D.S. 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