This statement is to inform you of our financial policy. We are committed to providing you with the highest quality dental care using only the best material and technology available in the market today. We are also commited to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. Our financial policy is intended to facilitate excellent service to you while minimizing out administrative costs.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract.

As a courtesy to you we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our office by signing the authorization on the Assignment of Benefits Agreement. In order for our office to file your insurance claim, you must bring a completed dental insurance form or proof of insurance at each appointment.

Payment is due at the time services are provided. Our office accepts cash, personal checks, MasterCard, Visa, Discover, and Debit Cards. Outside financing is available upon request and approval.

Returned checls and balances older than 60 days may be subject to collections fees and finance charges at the rate of 1.5% per month (18% annually). In the event of default, you will be obligated to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees that may be required to effect collection of this debt. Additionally, our office may charge you for broken appointments cancelled without 48-hour advance notice.

If you have any questions regarding our financial policy, please ask. We are commited to providing you with the most positive experience in dental care.

The undersigned agrees that if this account is not paid due, and our office should retain an attorney or collection agency for collection, the undersigned agrees to pay all costs of collection including cour costs, reasonable interest, reasonable attorney's fees and reasonable collection agency fees.