Payment Policy

Fill out the form and submit it to our office electronically below. If you’d prefer, you can download and print the PDF here.


This office files insurance as a courtesy to our patients. Additionally, we accept assignment of benefits from your insurance company so that we can receive payments directly. Ultimately, It Is the patient's responsibility to deal with his/her insurance company directly should any problems arise. Also, patients are responsible to pay their estimated co-payments directly to our office at the time of treatment. A patient's co-payment is quoted according to the information we receive from the insurance company. These co-payments are an estimate, not a guarantee. Insurance companies often will change treatment codes to provide for the minimum benefit payable. We do our best lo inform the patient of the estimated co-payment, taking all of the above information in to account. We can only guarantee our actual fee for any given service.

We expect and appreciate greatly either our estimated co-payment or payment in full at the time of the visit. We do not normally extend credit and do not offer in-house financing, however no interest payment plans through a third party are available for qualified applicants. If, for some reason, our co-payment estimate is off, either send a statement for the remaining amount (statements will go out once a month until the account is paid in full) or we issue a credit on the account which can be used toward future work or refund the patient directly.

Patients who keep an unpaid account balance over three months will be referred to an attorney. The patient will be responsible for any collection fees charged, including reasonable attorney fees(if applicable) by us or by the agency.

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