Billing & Cancellation We understand that emergencies arise that preclude you from keeping an appointment, but PLEASE remember that we have reserved an appointment time especially for you. We request that you give us at least a 24-hour notice to reschedule an appointment or a $50.00 fee will be charged to your account. This $50.00 charge must be paid before you are re-appointed. After 3 failed appointments you will be dismissed from our office. FINANCIAL POLICY Payment is due at the time of service. We accept Cash, Check, Visa/Mastercard, discover, American Express, Apple Pay, and Care Credit. Regarding Insurance: We file your insurance as a courtesy. The balance is your responsibility regardless if your insurance pays. We cannot file your insurance if you do not provide is with a copy of your insurance card. If we should file a claim for your dental services and your insurance company has not responded within 45 days, you will be expected to pay the remaining balance in full at that time. Please be aware that some of the services provided may not be covered under your insurance plan. All copays and deductibles are due at the time of service. Usual and Customary Rates Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. Minor Patients: The adult accompanying a minor and the parents (or guardians of the minor) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless accompanied by an adult. HIPAA Notice of Privacy Practice I acknowledge that I have received and read a copy of Dr. Jared D. Anway, DDS Notice of Privacy Practices. I have read the financial and cancellation policies. I understand and agree to this financial policy as well as the cancellation policy.Signature(Required)
