PREMIERE DENTAL GROUP

Our Financial Policy

We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time.  Your clear understanding of our financial policy is important to our professional relationship.

CASH PATIENTS

            Full payment is due at the time of service.

INSURANCE/PPO PROVIDER

It is our policy to collect all co-payments and deductibles at the time of service.  We will submit a dental claim to your insurance company on the date of service. Please contact our office regarding any unpaid claims so we can assist you. Any claim over 60 days will become your responsibility. Initial __________ 

NON-PREFERRED PROVIDERS

If we are not contracted with your insurance, we cannot provide you with accurate co-payments.  We will estimate your co-payment to the best of our knowledge and bill your insurance for you.  Once your insurance has paid, the remaining balance is due immediately. Please contact our office regarding any unpaid claims so that we may assist you. Any claim over 60 days will become your responsibility. Initial __________

BLUE SHIELD

Blue Shield does not reimburse non-preferred providers.  Therefore, you are responsible for the charges at the time of service.

PAYMENT METHODS

We accept cash, personal checks, Visa, MasterCard, Discover, and American Express.

All overdue accounts are subject to an interest charge after 90 days past due.  All accounts over 90 days will be sent to a collection agency, unless prior arrangements have been made.

CANCELLATION POLICY

We ask that you give us 48 hours notice if you need to cancel an appointment in order to prevent a charge.

Please feel free to speak to us if you have any questions.

I have read and understand the above financial policy and I agree to comply under the terms described.

Signature___________________________________________ Date____________________