Thank you for choosing us as your dental care provider. Our doctors and staff members are dedicated to serving your dental needs with the best professional advice, care, and service obtainable. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment being rendered. We are glad that you are here and we want to do our very best for you. We sincerely hope that your visit will be a pleasant and rewarding experience. If you have any questions during your dental exam today, please do not hesitate to ask.


We want to help remove financial barriers so you and your family can get the dental treatment that you need. Many patients have some type of dental insurance, and we are able and pleased to assist you in maximizing your benefits. We also understand that not all of our dental families have dental insurance, and we want you to rest assured that we do have payment options available to meet most patient’s needs. We accept cash, checks, VISA, MasterCard, Discover and American Express. We offer several flexible financing options because we do understand that monthly payments can help fit dental care into your budget. The first option is Lending Club (for those who qualify). With Lending Club, you can finance 100% of your treatment with no annual fees and allows you to finance treatment plans from $500 to $50,000. Lending Club offers several payment options: 0% financing from {6) (24) months, and low-interest extended plans from (6) months to (84) months dependent upon approval. This allows for flexible monthly payments – the length of term is determined by the amount financed. Much like Lending Club, we also offer Proceed Finance (for those who qualify). Proceed Finance offers low-interest financing all the way up to (96) months, dependent upon approval, with no required down payment. This financing option can be used for treatment plans anywhere from $2,500 to $60,000. We also accept CareCredit card payments (for those who qualify). CareCredit offers the same payment options as Lending Club. The major difference between Lending Club and CareCredit is that CareCredit serves as a credit card and can be used at a variety of health/wellness institutions. For patients that do not qualify for the above mentioned options, or do not want a credit check option, we offer an in house, two pay option, allowing for half down today, and the other half of the balance to draft within 2 weeks, before final treatment completion dates. Prior to treatment being placed on the schedule, a financial arrangement must be agreed upon and endorsed by the responsible party.


The parent or legal guardian that accompanies the minor child/children to the appointment is responsible for any payment due. In case of an emergency situation, all minors must be accompanied by a parent or legal guardian throughout the entire duration of the appointment.


We file all insurances for you outside of Medicare/Medicaid, and accept all insurances except Medicare/Medicaid and HMO plans. Insured patients will receive cost estimates broken down by insured and uninsured costs. For patients covered by insurance, we will accept assignment of benefits, if allowed by the plan. This means that you sign the portion of your insurance that “assigns” payment to our office. Please note that estimates are based on information provided by your insurance and are not a guarantee of payment. Only after a claim is submitted and processed by your insurance company can final payment be determined. As a courtesy, we file claim forms electronically, provide postage for special claims, and track claims for you.

In order for us to file your insurance we have to verify your current insurance benefits. Tb do so wewill need your current insurance card, photo ID, subscriber ID, and social security number. If we’re unable to verify your insurance information at your first visit, full payment will be due at the time of service. Also, you are responsible for all co-pays and deductibles. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Your claim will be filed immediately, and the benefits expected are typically paid within 30 days. The filing of an insurance claim does not relieve you from the responsibility of your bill or the timely payment on your account. If the claim is not paid by your carrier in 60 days, the unpaid portion will automatically become “self-pay” and notification will be issued for the unpaid portion. Out-of-network insurance reimbursement estimates are based on historical reimbursements of your dental insurance provider and not on stated percentages.

We file claims to many different insurance companies, and it is virtually impossible for us to know your individual insurance policies. Please be aware that some, and perhaps all, of the services provided may be considered by your insurance company to be NON-covered services and/or might be subject to a deductible in addition to your co-pay. You are responsible for any amounts your insurance company chooses not to pay, for whatever reason.

We will not become involved in disputes between you and your insurance company regarding non-covered charges, diagnoses, co-pays or deductibles. Please refrain from asking our office to change a diagnosis or procedure code in order for the visit to be covered by your insurance company.

It is your responsibility to let us know of any insurance changes in a timely manner. Feel free to contact your insurance company regarding unpaid benefits. We will gladly provide you with a letter which would include all pertinent information which you may sign and mail.

Secondary Insurance:

We do not file and do no accept assignment of benefits for secondary insurance; however, we are happy to provide you with the information that you need, allowing you to file and be reimbursed by your secondary carrier. You will need to request a dental claim form from your secondary carrier as we do not have these at the office since all of our claim filing is done electronically.

Late Payments:

If your payments are late, declined, or if you request a change in date or amount not in accordance to your agreement, a $35 processing charge will incur for each instance. In the event that multiple payments are declined, treatment will cease until payment is current and future treatment is paid in full. If treatment has been completed, full payment will be due immediately.


After all payments have been received and the patient account has a negative balance, the patient will be credited the exact amount to the form of payment originally used within 30 days.


If this account is assigned to an attorney or collection agency, I agree to be responsible for any attorney fees, collection fees, and court costs incurred. I understand that all future scheduled appointments will be canceled if my account is turned over to the collection agency.

Missed Appointments:

Once an appointment has been made, that time is reserved specifically for you. If you need to cancel an appointment, we ask for at least a 48-hour notice. This allows us to offer the appointment to another patient. If you fail to keep your appointments without letting us know in advance, a $50.00 charge will be applied to your account.

Returned Check and Missed Payments:

A returned check or missed payment fee of $35 will be added to your account for each missed payment and returned check. Before we accept another form of payment for reinstatement of any payment arrangement, all fees plus full payment for the amount(s) that did not clear must be paid in cash, or by Visa, MasterCard, AMEX, or Discover.

Electronic Communications Notice:

By signing below, you acknowledge that this office uses non-encrypted email, text, and phone messages for all communications. Best practice precautions are taken in an effort to protect your ePHI. By signing below, you agree to receive communications through these mediums from our office, and you agree to our use of these mediums in communicating with your insurance, or any other referring providers.

Records Release Fee:

Should a patient or their proxy request records to be released, we will provide a records release form that the patient must sign, prior to the release of any records. For records release, a $30 fee will be applied to the patient’s account, and is due immediately.

Proceed e1551124996369
Payment icons 300x27 1


To support your evolving needs, we are introducing a new integrated online solution. You can learn about CareCredit, apply directly for the CareCredit credit card and pay your invoices online, all-in-one place. It’s as simple as clicking the link below!