Financial Policy

Dr. Melvin and his staff are committed to providing patients with the best possible dental treatment. Please understand that a payment is part of your treatment. The following is a statement of our Financial Policy, which you are required to read and sign prior to any treatment. 

Each patient or guardian assumes all financial responsibility for services rendered. Each patient or guardian agrees to pay reasonable costs and expenses incurred to collect amounts owed, including attorney’s fees, collection agency fees, and court costs. A service charge of $32.00 shall be applied to each time a check is dishonored. Full payment via an acceptable means is due at the time of service. Acceptable means of payment include: cash, check, AMEX, VISA, MC, and insurance claims. 

Your dental insurance coverage is a contract between you, your employer, and the insurance company. You should first contact your insurance company with any questions regarding your benefits. Responsibility for payment of fees is the obligation of each patient. Our office will file your insurance claims as a courtesy to you. However, any unmet deductible or estimated portion is due at the time of service. Any unpaid balance after your insurance company has paid is your responsibility.  If your insurance company has a direct reimbursement policy, you are required to pay for your services in full at the time they are rendered. You are responsible for payment of your balance if your insurance company does not pay within 30 days of filing the claim.

Dr. Melvin’s office requires at least 24 hour notice to cancel an appointment. If you miss two (2) scheduled appointments without 24 hour notice, you will be required to pay in advance to schedule your next appointment. If you do not keep your prepaid appointment, your payment will be forfeited. Per your insurance company a cancellation fee may be charged. 

Past due accounts will be subject to a billing fee of $5.00.

The signature below acknowledges understanding and compliances with the above stated policies. I ___________________________________________ assume financial responsibilities for services rendered as detailed in this policy.

	___________________________________ 			__________________
	Signature							Date