• If patient is a minor, we need:

  • Primary Dental Insurance Information

  • Secondary Dental Insurance Information


    Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care. Please understand that payment of your bill is considered part of your treatment. Payment is due at the time service is provided. We accept cash, personal checks, MasterCard and Visa. Please Note: Returned checks will be subject to a $30.00 fee. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges incurred up to 35% of the outstanding balance.

      If you have Dental Insurance:
    • As a courtesy to you, we will process your insurance claims. Please understand that we will provide an insurance estimate to you. however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate Is as accurate as possible, based on tne information you provide to us.
    • All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.
    • Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
    • We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This farm instructs your insurance company to make payment directly to our office.
    • The deductible and co-payment, which is the estimated amount not covered by your insurance company, is due the day services are rendered.
    • Insurance payments are ordinarily received within 60 days from the time of filing, if your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim ts denied, you will be responsible for paying the full amount at that time. After 90 days have passed, we will charge interest to any unpaid balance to your account at 1.9%, per month.
    • We will cooperate fully with the regulation* and request* of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

    FAILED APPOINTMENT: Your appointment time is reserved just for you, so that we can provide you with our fullest attention. We realize that at times you may need to reschedule your appointment due to unforeseen circumstances, if you need to cancel your appointment, kindly give us at least 24 hours notice so we can accommodate other patient* who ire waiting to receive treatment. In the event you do not show up for your appointment or do not cancel within 24 hours, your account will be charged a $35.00 fee far a failed appointment. In the event cf future failed appointments, your account will be charged 335.00 for each occurrence After three failed appointments, we reserve the right to dismiss you from our practice. LATE ARRIVAL: Late arrival for a schedule appointment leads to inadequate time to accommodate the remaining patients on the schedule. As such, late arrivals of greater than 10 minutes may not be seen due to lack of time available. In addition, those patients who are on the schedule and have arrived at their assigned time will be seen first. We will try to accommodate late arrivals, time permits.

    CONSENT: I have READ, UNDERSTAND and AGREE to the above terms and conditions. I AUTHORIZE my insurance company to PAY my dental benefits DIRECTLY to my DENTAL OFFICE. I. the undersigned, hereby authorizes Smiles For Life LLC to take X-Rays, make study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Heflelfinger to make a thorough diagnosis of my or my dependents dental needs. I also authorize Dr. Heffolfinger to perform any and ail forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk and that in rare instances permanent parasthesia may result I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made I further understand that a finance, rebilling, collection charge or attorney fee will be added to any overdue balance

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