3278 Noble Avenue, San Jose, CA 95132 Tel. No. (408)937-8333
990 Bay Street, Mountain View, CA 94040 Tel. No. (650)968-4000
OUR FINANCIAL POLICY
Thank you for choosing us as your dental health care provider. We are committed in providing you with a successful treatment. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy which we require that you read, agree to and sign prior to any treatment.
All patients must complete our “Patients Information Form” before seeing the dentist.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE. Partial payment may also be accepted depending upon the total amount. Please ask for details.
We do offer an extended payment plan with prior credit approval.
We accept cash, check, and Visa/Mastercard. Any returned check is subject to a $100 penalty charge regardless of the amount issued.
We accept assignment of insurance benefits with current eligibility and coverage. The balance is your responsibility if your insurance company does not pay. An original insurance claim form with the subscriber’s signature will be needed to bill your insurance, specifically, on your first dental care visit. Please be aware that some, perhaps all, of the services provided may be “non-covered” services and not considered reasonable and necessary under your dental insurance.
Adult patients are responsible for full payment at the time of service.
Parents or guardians accompanying a minor are responsible for full payment of the services. For unaccompanied minors, non-emergency treatment will be denied unless charges have been preauthorized to an approved credit plan, Visa/Mastercard, or payment by cash or check at the time of service.
We have reserved a time for you. Please give us at least 24 hours advance notice if you cannot make the appointment. No shows (failure to attend the appointment) and cancellation of appointments not made at least 24 hours in advance will be charged $25 payable no later than the time of your next visit. Please help us serve you better by being on time and keeping your scheduled appointments.
REQUEST FOR DENTAL RECORDS
If for any reason that copies of dental records including radiographs are requested by the patient, a fee of $25 will be charged.
THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICY. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS, COMMENTS OR CONCERNS. I HAVE READ, UNDERSTOOD AND AGREED TO THE ABOVE FINANCIAL POLICY.
PATIENT/RESPONSIBLE PARTY ______________________________________ DATE ________________________