If you have dental insurance, we ask that you become familiar with your program benefits and financial obligations. Our staff is here to help process your claims and estimate your dental benefits. It is important to remember that the insurance contract is between you and your insurance company. Should you have any questions regarding your specific dental insurance plan, or should you encounter a problem with reimbursement, please contact your employer and/or insurance company first. As a courtesy to our patients, we will file your primary insurance claim. We require that you make your estimated co-payment before leaving our office. For your convenience, we do accept the following payment options: cash, check, Visa, Mastercard, Discover, American Express, and Care Credit.
I hereby authorize and request my insurance to pay my insurance benefits directly to the dentist or dental group. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf and my dependents. If a collection action is necessary, I understand that I will be responsible for all collection costs, court fees, processing fees, and interest at 1.5% per month up to 18% annually.
In the event that you either cancel your appointment with less than 48 hours notice of your appointment time or no show for your reserved appointment, you will be charged for the visit. The missed hygiene appointment fee is $60 per hour and the missed Dr appointment fee is $90 per hour. Extenuating circumstances will be considered on a case by case basis by Dr. Daly and Dr. Cook.
I hereby authorize and request my insurance to pay my insurance benefits directly to the dentist or dental group. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf and my dependents. If a collection action is necessary, I understand that I will be responsible for all collection costs, court fees, processing fees, and interest at 1.5% per month up to 18% annually.
Appointment Agreement
We value our patients. We are always mindful that your time is very important to you. We make every effort to see our patients on time and to complete procedures in a timely manner. We expect that our patients are courteous in arriving on time and keeping their appointments so that we are able to do so.In the event that you either cancel your appointment with less than 48 hours notice of your appointment time or no show for your reserved appointment, you will be charged for the visit. The missed hygiene appointment fee is $60 per hour and the missed Dr appointment fee is $90 per hour. Extenuating circumstances will be considered on a case by case basis by Dr. Daly and Dr. Cook.