FINANCIAL POLICY Periodontics and Oral Implantology
We are proud to be a part of a team whose primary mission is to deliver the finest and most comprehensive Periodontal and Implant treatment available. To assist you with your health care investment, we are providing the following payment guidelines:
A. On the day of treatment, patients with insurance are required to pay their estimated portion of the fee. Patients without insurance are required to pay in full at the time of service. New patients will be given a written estimate of the charges at the initial consultation.
B. Patients who carry insurance should remember that services are rendered and charged to the patient, not the insurance company. We will be happy to file the insurance claim for you, but please understand this is not a guarantee of payment by your insurance company.
C. A pre-authorization for proposed treatment can be obtained from your insurance company. This will give you a better idea of what aspect of your care that they will cover. Their response typically takes 3-6 weeks. We will notify you of their response.
D. If your insurance does not pay the balance of your account within 45 days, it will be your responsibility to pay the outstanding amount.
E. Payment options include Cash (this includes checks and money orders), Bank Cards (Visa and Mastercard) and financing. The financing application can be filled out in our office and submitted to the financing company. An administration fee may be required for some finance groups.
F. A statement will be sent to you for any balance owed. Delinquent accounts will be referred to a collection agency.
In an effort to keep costs down we ask that you give 72 hours or more notice for appointment cancellations. Your appointment time has been scheduled exclusively for you and a late cancellation or rescheduling will result in a $45 charge. Cancellation of a surgical appointment less than one week in advance will result in a 5% of the total surgery charge.
Assignment and release: We feel your privacy is very important and we will do everything possible to protect your privacy, including adhering to our attached and posted office HIPAA policy. Your signature authorizes required clinical information to be released to process billing for services rendered. Insurance benefits may be paid directly to your doctor. I understand that I am financially responsible for non-covered services.
I hereby acknowledge and agree to the above mentioned office policies.
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Signature of Patient or Guardian Date
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Insurance/Payment 
