Payment in full is expected at the time of treatment. Patients with dental insurance must provide accurate and
complete insurance information. We will be happy to file for your insurance benefits as a courtesy to you, but we are
not obligated to do so. Our relationship is with you and not your dental insurance company. Your dental insurance is a
contract between your employer and the insurance company. The percentage covered for each procedure is determined by how
much your employer has paid for coverage.
At the initial appointment, you will be responsible for your portion of the fees not covered by your insurance for
that appointment and payment is expected. Prior to completing any restorative treatment, however, we will provide you
with a cost estimate of our total fee, your estimated insurance coverage, and your estimated out-of-pocket costs. Please
remember, these are only estimates and may change during the course of treatment. Sometimes, treatment alternatives become
necessary for various reasons, which may increase or decrease treatment costs. Further, most insurances do not tell us
exactly what they will pay, so we are only giving you our best guess.
Any amount not covered by your insurance company is payable at the time services are rendered. These fees may include
deductibles, co-payments or certain procedures not covered by your insurance policy. For your convenience, we accept cash,
personal checks, and Visa/MasterCard. Any returned checks will incur a $30 processing fee. We cannot accept responsibility
for negotiating a disputed claim and allow a maximum of 45-days for your insurance company to clear account balances. If
your insurance does not pay within 45 days of the treatment rendered, we shall expect payment in full from you. A late charge
of 1.5% per month, or a minimum late charge of $30.00 will be added to unpaid balances over 45 days past due. After 90 days
from the time of service and attempts to collect outstanding funds, parents/guardians not fulfilling their financial obligation
will be sent to collections.
If you have any questions, we will be happy to assist you. We look forward to beginning a wonderful relationship with you
and your child! Please do not hesitate to call.
9818 Paramount Blvd., Suite A, Downey, CA 90240 | 562.92.SMILE – 562.927.6453 | Fax 562 927-3400
