CONSENT FOR SERVICES AND FINANCIAL POLICY
As a condition of treatment by this office, payment is expected when services are rendered.
Patients with dental insurance understand that all dental services are charged directly to the patient and that he/she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot guarantee actual payments made by insurance companies and can only give estimates of such payments. If we do not receive payment from your insurance carrier within 120 days, you will be responsible for payment of your treatment fees and collection of your benefits from your insurance carrier. Any fee estimate the this dental care can only be extended for a period of six months from the date of the patient examination.
PAYMENT OPTIONS: Cash, Check, Visa, Mastercard or Discover cards. CareCredit Payment Plans (subject to application & credit approval).
A fee of $25 is charged to patients who miss or cancel their appointments more than 3 times without 24-hour notice.
Hamburg Dental Center charges $25 for returned checks.