Financial Policy

Patient First Name:

Patient Last Name:

Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy which we require that you read and sign prior to your treatment.

It is our policy that all outstanding balances are paid in full. Co-pays, deductibles, and co-insurance (including non-covered services) are your responsibility.

WE ACCEPT CASH, CHECK, MASTERCARD, VISA, AMERICAN EXPRESS, DISCOVER and DEBIT CARDS. We reserve the right to assess a fee of $35.00 for returned checks, in addition to bank fees.

Regarding Insurance

We accept a variety of insurances and are participating providers for several networks. Please refer to your insurance handbook or your insurance carrier for questions regarding your coverage. As a benefit to you, we will submit your services to your insurance.

Minor Patients

Co-payments for all services are due at the time of the appointment. Parents/guardians should arrange for payment if not accompanying their minor child to his/her appointment.

Acknowledgement and Acceptance

I have read and fully understand the above. I authorize the release of information for the purpose of payment and insurance benefits. I authorize payment directly to First Choice Dental for services rendered to me and/or my dependents.

I further accept responsibility for payment of co-payments, deductibles, coinsurance and any services that are not covered or paid by my plan. Balances due on my account shall be paid in full upon receipt of a current statement.