We have made our new patient forms available to you as Adobe Acrobat files. For your convenience, we recommend printing and completing these forms at home. Please remember to bring your completed forms with you for your first appointment. If you have any problem getting these files to print properly, please call our office and we will gladly send or fax them to you.
- New Adult Form
- New Child Form
- Insurance and Financial Agreement Form
- HIPAA Notice of Privacy Practices
- HIPAA Consent for Disclosure Form
A) Prepay Courtesy (for fees over $250)
A prepayment courtesy of 5% will be subtracted from the total patient obligation (not from any portion due from insurance company), if the patient obligation is paid in full prior to the first treatment visit.
B) Care Credit (for fees over $300)
We are pleased to offer CareCredit to our patients. CareCredit is a convenient, no initial payment, low monthly payment plan to for large dental treatments. It is specifically designed for cosmetic dental procedures and related specialties. Offering CareCredit allows us to make the smile you've always wanted affordable. You may apply quickly and securely over the web. Please visit CareCredit for instant online pre-approval today.
C) Pay as You Go
Any time your treatment is under $250 or the portion you owe after insurance payment is under $250, we will ask you to pay that on the day treatment begins.
FORMS of PAYMENT and BALANCES DUE
In order to facilitate access to the very best care possible, we accept all major credit cards, cash, and personal checks. Balances over 21 days will incur a finance charge of 18% APR.
INSURANCE
It is our pleasue to assist you in maximizing your insurance benefit by completing your claim forms. If your carrier is up to date, the claims wil be transmitted via internet (or mail with some carriers) before the end of the treatment day. As a courtesy, in addition to filing the claim, if you prefer, we will initially ask you only for your estimated copayment. Please understand that this is ONLY AN ESTIMATE, and is based on the information available to us.
The range of benenfits depends solely on what your employer wishes to purchase. Some plans cover as little as 30% or as much as 100% of dental services, with most falling in the 40% to 80% range.
Some plans base the amount of benefit on a schedule of fee arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan.
The financial obligation for dental treatment is between you and our office.The insurance company is responsible to you, and not our office. Once your carrier has paid the claim, any difference will be due upon receipt of the insurance company's Explanation of Benefits or our statement, whichever is received first. If, for any reason, we have not received your insurance carrier's payment 90 days after the claim, the remaining balance will be due and payable by you.