Patient Information

Financial Information

1. Payment is expected at the time services are rendered. We accept the following methods of payment.

a. Cash
b. Personal Check
c. Visa/Mastercard
d. American Express
e. Discover
f. Care Credit (an interest free payment plan available in office)*

2. Insurance assisted patients. We will process your insurance and accept assignment of benefits (excluding Mich. Dental Plan, or any plan that pays benefits directly to the patient) with the following agreement:

a. The estimated co-pay is paid in full at the time of service.

b. If there is any difference between estimated insurance payment and the actual insurance payment after it is received, the patient will pay the balance in full within 30 days.

c. If after 60 days of billing the primary insurance, we have not received payment, any remaining balance will be transferred to the patient. The balance will be due within 30 days. If additional payment is received from the insurance company, it will be refunded to the patient within 30 days.

d. If the insurance pays more than estimated, we will refund the difference to the patient within 30 days

3. If the patient has more than one insurance plan, we will process insurance and accept benefits with the following agreement:

a. Insurance is a third party.

b. Any balance remaining after both insurance companies have paid will be paid by you within 30 days of receiving a response from the second carrier.

c. If we have not received payment from the secondary insurance after 45 days, the patient will be responsible and the balance will be transferred to the patient . The entire balance will be due within 30 days. If any additional payment is received from the insurance company, it will be refunded to the patient within 30 days

4. Any patient balances over 30 days will be assessed a finance charge of 1.5 % per month (APR 18 %), calculated from the date of service.