Financial

Forms-FinancialWe never want costs to stand in the way of quality treatment, which is why we are dedicated to providing our patients with care that is both effective and affordable. Your treatment plan will include a breakdown of all applicable fees, and we will inform you of all costs before treatment is administered.

We offer a variety of payment options to meet your needs. Our office accepts payments by cash, checks, and Visa, MasterCard, American Express and Discover credit cards. If full payment is made at the onset of treatment, we offer a fee discount. We also offer a discount to siblings receiving treatment.

Affordable Financing Options
Don’t let finances stand in your way for achieving the beautiful, healthy smile you deserve! We are pleased to offer in-house financing and third-party options through CareCredit to help make your treatment more affordable. These flexible payment options allow you to pay for your treatment over a period of time so you can focus on what matters most – keeping your smile healthy!

If you have any questions about financing or payment, ask us! We will thoroughly explain your choices and work hard to accommodate you.

Insurance

Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts.

When you first visit our office, bring your current insurance card with you. If you change insurance companies or join another employer’s plan, please be sure to let us know. If an insurance referral is necessary, please bring the completed form with you to your appointment.

Please note: Although we file all insurances, we do not accept Medicaid or CHIP insurance plans.

We will fully attempt to help you receive full insurance benefits; however, you are personally responsible for your account, and we encourage you to contact us if your policy has not paid within a reasonable timeframe. If we are not contracted under your insurance, you will be given a copy of services and charges to file with your insurance claim form.

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Patient Information

Parent/Guardian Information

Emergency Contact

Insurance Information

Dental History

Medical History

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.