We are committed to providing our patients with the best dental care possible. Included in that commitment is an open dialogue about our fees and financial policies. This agreement provides a written statement of our policies and procedures. Please review the following information. If you have any questions, please discuss this information with the doctor or his representative.
1. Payments
Payment in full is due at the time of service. If you have dental insurance, your estimated co-payment is due at the time of service. For your convenience, we offer payment options in addition to cash and checks, including credit card payments. We accept the following credit cards: Visa, Mastercard, Discover, American Express, and bank debit cards.
2. Health Insurance
Your insurance policy is a contract between you and your insurance company. As health care providers, we are not a party to that agreement. We want to emphasize that our relationship is with you, not your dental benefits provider.
There are no guarantees of health insurance benefits. If your insurance does not cover all or part of the treatment provided, you will be responsible for payment of fees that are not reimbursed by insurance. However, we are committed to helping our patients maximize their benefits and we will work with you to achieve the maximum benefits for your coverage.
If you have dental insurance, we will complete and submit a claim form to your benefits provider as a courtesy to you. If your insurance has a preferred provider list and we are not on that list, you may be responsible for additional costs.
3. Treatment Plan Estimate.
Once we have assessed your dental condition, we will present you with a written treatment plan. The treatment plan includes a detailed estimate of each procedure’s total fee, separated by the expected benefit portion and the patient’s obligation. Please note that dental benefits are subject to various limits as determined by your benefit provider. All co-payments are due at the time of service. The estimate of fees is guaranteed for sixty (60) days. After such time, the fees are subject to change.
4. Late Fees
Should your account exceed sixty (60) days, one and one-half percent (1.5%) interest per month (18% per year) will be charged. In the event your account exceeds ninety (90) days after all insurance claims have been paid, your account will be sent to a collection agency and/or small claims court and an additional $85.00 will be charged for administrative fees. In the event of incurred costs for your default of payment, you agree to be responsible for all attorneys’ fees and other court costs associated with enforcing this agreement.
5. Returned Checks
Patients writing checks that are returned for any reason are subject to a “return check charge” of $35.00. In the event that a check is returned, we will require cash or a cashier’s check as payment for the original balance in addition to the returned check charge.
6. Cancelled Appointments
As a courtesy to them, we will remind our patients of their appointments by telephone. Once an appointment has been made, this scheduled time has been reserved for you. We understand that circumstances arise that may prevent you from making your scheduled appointment. However, please note that should you fail to show for your appointment or fail to cancel your scheduled appointment within twenty-four (24) hours of the scheduled appointment time, you may be subject to a charge of $250.00.
Privacy Statement
We are committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. This Statement of Privacy applies to our website and governs data collection and usage. By using this website, you consent to the data practices described in this statement.
Collection of Your Personal Information
We collect personally identifiable information, such as your e-mail address, name, home or work address, or telephone number. We also collect anonymous demographic information, which is not unique to you, such as your ZIP code, age, gender, preferences, interests, and favorites.
There is also information about your computer hardware and software that is automatically collected by this website. This information can include your IP address, browser type, domain names, access times, and referring website addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding the use of this website.
We encourage you to review the privacy statements of websites you choose to link to from the website so that you can understand how those websites collect, use, and share your information. We are not responsible for the privacy statements or other content on any other websites.
Use of Your Personal Information
We collect and use your personal information to operate the website and deliver the services you have requested. We may also use your personally identifiable information to inform you of other products or services available from our affiliates and us. We may also contact you via surveys to conduct research about your opinion of current services or of potential new services that may be offered.
We do not sell, rent, or lease our customer lists to third parties. We may, from time to time, share data with trusted partners to help us perform statistical analysis, send you emails or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services and they are required to maintain the confidentiality of your information.
We do not use or disclose sensitive personal information, such as race, religion, or political affiliations, without your explicit consent.
We will disclose your personal information without notice only if required to do so by law or in the good faith belief that such action is necessary.
Use of Cookies
This website uses "cookies" to personalize your online experience. A cookie is a text file that is placed on your hard disk by a webpage server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.
One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the web server that you have returned to a specific page.
You have the ability to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the website.
Security of Your Personal Information
This website secures your personal information from unauthorized access, use, or disclosure. This website secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use, or disclosure. When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use of encryption, such as the Secure Socket Layer (SSL) protocol.
Changes to This Statement
We will occasionally update this Statement of Privacy to reflect company and customer feedback. We encourage you to periodically review this Statement to be informed of how we are protecting your information.
