1. Our Practice is committed to providing the best treatment for you at a fee that is reasonable, usual and customary for this area. Full payment is due at time of service. Payment options include:

2. Minors: MUST BE ACCOMPAINED BY A PARENT OR GUARDIAN FOR ALL APPOINTMENTS UNLESS A WRITTEN CONSENT IS PROVIDED. The Adult accompanying the minor is responsible for full payment.

3. Your scheduled appointment time has been reserved at your request. All patients who fail to arrive for their reserved appointments or who cancel without 48 hours advance notice may be charged a missed appointment fee of $100. Please note that this missed appointment fee is NOT covered by any insurance plans and is your responsibility to pay. We require this notification in order to offer this time to another patient in need. Please help us avoid charging this fee by keeping your scheduled appointment or giving us the required 48 hours’ notice.

The following applies to those patients with dental insurance:

Please bring your insurance card with you on each visit. If at your first appointment we are unable to verify your dental insurance or cannot obtain a list of benefits, full payment is due at the time services are rendered. The responsibility of providing complete and accurate insurance information to our office staff belongs to you, the patient. Patients are to pay their deductible and the estimated co-payments at the time treatment is rendered. Legally, we cannot waive co-payments, deductibles, or coinsurance amounts.

In the state of Maryland, Insurance companies are required to send payment within 30 days. If full payment is not received from your insurance carrier within 60 days, the balance becomes your total responsibility.

I have read the above policies and agree to abide by them.