Thank you for choosing our office for you dental needs. We are committed to your treatment being successful. 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 read and sign prior to any treatment.
All patients must complete a patient history and inform our office of insurance before seeing a doctor. Full payment
is due at time of service. We accept Cash, Visa/MasterCard and Discover Card as forms of payment. Any return
checks will be subject to a $25.00 bank return fee.
Regarding Your Insurance
As a courtesy to our patients we will bill your insurance company for your reimbursement, but please note that we
cannot bill your insurance company on your behalf unless you give us your insurance information and a copy of your
insurance card.
Your insurance Policy is a contract between you and your insurance company; we are not a party of that
contract. Please be aware that some and perhaps all of the services may be non-covered services according to
your carrier.
Regarding Payment of Dental Services
Payments for all services are paid out as follows:
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For all general treatments which include, Operative work (Fillings), Sealants, Emergency, Recalls, Perio
Maintenance, Diagnostic, Radiographs and Consults payment in full is expected on day of service.
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Prosthetic Service which includes Crowns, Bridges, Dentures, Onlay/Inlays and Implants, a 50% deposit will be
required at the initial visit; the remaining balance will be divided into the number of visits needed to
complete your treatment. (Note: Full remaining balance is required by the date of insert)
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Although we are currently a Delta Dental and Horizon Blue Cross - Blue Shield of New Jersey (Traditional Plan
Only) provider, you as the patient may be responsible for some or all of the non- covered services according to
your insurance carrier. Participants of such plans must come prepared to pay in full on the date of service your
obligations for each service rendered.
Late Charges; Interest Charged on Unpaid Balance
Bills for our services and costs incurred on your behalf will be submitted to you no less frequently than monthly.
Our bills are payable upon receipts. If your monthly bill remains unpaid for 30 days, you will be
charged a late fee equal to 6% of the full amount then past due. In addition to such late fee, an
administrative charge shall be imposed on all past due balance which shall be calculated at the rate of
20% per annum (1.67% per month, until full payment is made).
Failure to Pay; Costs of Collection; Attorney's Fees
If you do not pay your bill(s) or any portion of your bill(s) rendered in accordance with this Agreement, we may
file a lawsuit against you. If we file a lawsuit, you shall also be responsible for paying all court costs and
reasonable attorney fees. It is agreed that reasonable attorney's fees shall be deemed to be equal to 25% of the
total outstanding balance of your bill, inclusive of any late fees and interest.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary
for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual
and customary rates, (with the exception of Delta Dental and Blue Cross- Blue Shield Traditional).
Adult Patients
Adult patients (18 years or older) are responsible for full payment at time of service.
Minor Patients
The adult accompanying a minor and the parents (or guardian of the minor) is responsible for full payment. For
unaccompanied minors, treatment will be denied.
Missed Appointments
As a courtesy, our office confirms 2 days prior to each scheduled appointment. Please note that it will be each
patient's ultimate responsibility to notify our office within 48 hours in the event that an appointment may need to
be rescheduled. Unless cancelled at least 48 hours in advance, our strictly enforced policy is to charge for missed
appointments at the rate of a normal office visit ($85.00). Please help us serve you by keeping scheduled
appointments.
