Financial and Appointment Policy

We’re committed to providing you with excellent care and creating a trusting partnership with you. Please help us to serve you and other patients by keeping your scheduled appointments. As a courtesy to you we attempt to confirm all appointments in advance. In order to provide available time for our patients 2 business days are required for appointment changes or cancellations. The minimum short notice cancellation and or broken appointment fee is $50.00.

 

For All Patients

For self-pay patients kindly pay in full at time of treatment. We accept MasterCard, Visa, Discover, personal checks and cash. To help you prepare for procedures other than routine visits we will prepare an estimate of your fees, including any estimated insurance payments.

 

We ask that you pay your estimated portion at the time of treatment. You will receive monthly statements during the course of your treatment to keep you informed of the status of your account. This includes pending insurance claims. Monthly finance charges will be made to account balances 60 days from the date of service.

Insured

We verify your coverage for dental services with your insurance company and will bill your insurance provider directly as a courtesy to you. We estimate insurance payments as closely as possible. This information is based upon information received from your insurance provider. But you’re responsible for any fees incurred in our office not covered by your insurance. Please note that our charges and agreement is with you. And we’re billing your insurance as a courtesy to you.

Non-Insured

 

If you are unable to pay in full at the time of service we offer a dental line of credit with Chase Health Advance. You can get up to 12 months interest free. Balances not paid in full at time of treatment must be pre-approved by the business office and will be subject to a finance charge of 1% per month.

 

Please ask if you have any questions about our fees, financial/appointment policy or your responsibility at any time. Your clear understanding of our policies is important to our professional relationship. Thank you!

 

It is my responsibility to monitor my insurance benefits including: knowing how much coverage I have, tracking remaining benefits, what benefits are covered and at what percentage. I agree to follow up and make sure that my claims are paid within my insurance deadlines. I understand that Dr. Murphy’s staff will assist me, but I am responsible. __________Initial

 

Responsible Party Signature____________________________________