Financial Policy

MELGOSA DENTAL FINANCIAL AGREEMENT

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

GENERAL:
Please 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 any other services not directly provided by the dentist.

MISSED APPOINTMENTS:
Unless we receive notice of cancellation 24 hours in advance, you will be charged an hourly rate for your appointment. Because our office is closed on Fridays, this does not count as a business day for the purpose of this contract. Please help us serve you better by keeping scheduled appointments.

You will be charged an hourly rate of $75 for hygiene appointments and $100 per hour for treatment appointments with Dr. Melgosa.

INSURANCE:
Please remember that your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, our office provides certain services, including pre-treatment estimates, which we send to the insurance company at your request. It is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire about what benefits your employer has purchased for you. If you have any questions concerning the pre-treatment estimate and/or fees for service, it is your responsibility to have these answered prior to treatment to minimize confusion. 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 or not your insurance company pays any portion.

PAYMENT:
Full payment is due at the time of service. If insurance benefits apply, estimated patient co-payments and deductibles are due at the time of service unless other arrangements are made. If payment is delinquent, the patient will be responsible for payment of collection fees, attorney fees, and court costs associated with the recovery of the monies due on the account.

Office Hours: Mon-Thurs 8:00 AM - 5:00 PM, closed for lunch from 12:00 PM to 1:30 PM. Office is closed on Fridays.