Thank you for choosing and entrusting us as your healthcare provider. As a courtesy to our patients, it is our office policy 

to bill your insurance company for treatment provided, at the completion of each appointment. Please bring your current 

insurance card to each visit and notify our office if you have any changes to your insurance coverage.

We do not participate in some of these programs. Please check with your insurance company to see if we are providers of your plan. 

It is your responsibility to obtain initial referral forms, etc. required by your particular insurance company. This also includes follow-up 

visits and visits to other physicians in our group. Please be aware that if you are seen out of network, you are liable for the difference in 

coverage benefits. Some HMO/PPO/Managed Care Primary Care Physicians require all x-rays be performed at their office only. Please check with 

your physician before your appointment.

You will be expected to pay your co-pay prior to seeing your physician. The co-pay requirement cannot be waived by our practice, as it is a contractual

agreement between you and your insurance carrier and the carrier requires that all co-pays be paid prior to any services being rendered. If you

do not have your co-pay at the time of your visit, you will be required to reschedule your appointment. You are responsible for any co-insurance, 

deductibles or non-covered services as required by your insurance. You will receive a statement from our office indicating what your insurance has paid. 

Any remaining balance is due upon receipt of that statement.

(Auto, Third Party Liability or no medical coverage at all

Payment is due at time of service. We require a $400.00 deposit at time of service.)

All of our providers are participating physicians with Medicare. We will file all charges (including x-rays, braces, and etc.) with your Medicare and your supplemental insurance, 

if applicable. If you do not have supplemental insurance, you will only be billed for the 20% not paid by Medicare or any deductible that has not been met.

A charge will be assessed per form. A payment of $25.00 is required before the form(s) will be completed.

Our office requires authorization from your employer or your third-party administrator in order to schedule your initial visit.

If you are a minor under the age of 18, your parents and/or guardian are required to accompany you to our office before treatment can be rendered. You need to make arrangements 

prior to being seen with your parent and/or guardian for payment to be made at the time of treatment. The financial responsibility for the minor rests with the accompanying adult, 

regardless of financial arrangement between a minor's parents and/or guardian.

For your convenience, we do have x-ray facilities in the building. If x-rays are indicated in your treatment, charges are handled in the same

manner as the physician charges. If you have had x-rays taken somewhere else, please bring them with you to your appointment.

In the event we need to have lab work drawn, our office uses outside laboratory services. You will receive a separate bill for these lab services. It is always your 

responsibility to see that your account is paid, regardless of insurance or any other arrangement (such as litigation or workman's comp). Patient is responsible 

for any costs associated with collecting any owed balances, including but not limited to, collection agency fees, attorney fees, and court costs.