Thank you for choosing North Hill Dental as your dental provider. We are committed to ensuring that your treatment is successful. Please understand that payment of your bill is considered part of your treatment. The following statement of our financial policy, which we require you to read and sign prior to any treatment.

GENERAL
Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office procedures, medications and also any other services not directly provided by the dentist.

APPOINTMENT CANCELLATION
We understand that situations arise in which you must cancel your appointment. Therefore, we request that if you must cancel your appointment you provide us 24 hours’ notice. Appointments that are canceled less than 24 hours’ may be subject to a $75.00 cancellation fee per scheduled hour. Patients who do not show up for their appointments without a call to cancel will be considered as a No-Show. Therefore, a no-show appointment is also subject to a $75.00 fee per scheduled hour.

INSURANCE
Please remember your insurance policy is a contract between you and your insurance company. We are not party to that contract. As a courtesy to you, our office will do our part in billing the insurance company you have provided the information for. This includes pre-treatment estimates which we send to the insurance company at your request. It is physically impossible to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. If you have any questions concerning a pre-treatment estimate and/or fees for service, it is your responsibility to have these questions answered prior to treatment to minimize confusion on your behalf.
Please be aware that some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility, whether your insurance company pays any portion.

PAYMENT
FULL PAYMENT is due at the time of service. If insurance benefits apply, ESTIMATED PATIENT COPAYMENTS and DEDUCTIBLES are due at the time of service, unless other arrangements are made. Patients with no insurance are subject to a 5% discount if you are to pay with CASH or CHECK ONLY. Patients who want to pay with a CREDIT/DEBIT CARD may be subject to a 5% service fee.

Unpaid balances over 120 days old will be subject to a monthly interest rate of 1%. If payment is delinquent, the patient will be responsible for payment of collection.

By signing this Financial Agreement, I understand and agree to the terms and conditions above.