Patient Information

Patient Forms
Our New Patient Forms are now available online! We are proud to make our patient forms available online so you can complete them at your leisure – saving you time waiting in our office and giving you time to carefully review our policies and procedures. If you would like to complete the form online before arriving at our office, please click the link at top of page to receive Login information. You can also click link below to download the form in PDF format. You may print out the form and bring it to your first appointment.

Financial Policy
HIPAA   Acknowledgment
HIPAA  Policy
Release of Records

Forms require Adobe Acrobat Reader to view. If you do not have Adobe Acrobat Reader, you may click the link below for a free download.

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Payment Options
For your convenience, we accept cash, checks, Visa, MasterCard, Discover, American Express and CareCredit® (3mo, 6mo & 12mo No Interest). Our treatment coordinator is always available to help you with your dental plan and can assist you as you decide on payment options prior to beginning your dental treatment. Full payment is due at time services are rendered, unless prior financial arrangements have been made.

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Insurance
If you have dental insurance, we will be happy to help you determine the coverage you have available. Your insurance coverage however is a contract between you, your employer and the insurance company. Our office accepts all major insurance plans. We are an in-network provider for Ameritas, Assurant, CIGNA, Delta Dental, Guardian, Humana, MetLife and Principal Financial Group.

As a courtesy, our staff will promptly and efficiently process insurance claims. We will collect ONLY your patient portion at time of treatment. We will do all that we can to ensure your benefits are being used in the best way possible. We cannot guarantee payment of your claims, or accept the responsibility of negotiating claims with insurance companies or other persons. If your insurance company pays only a portion of your treatment or rejects your claim you are responsible for full payment of services rendered. Claims not paid within 60 days of date of service become the responsibility of the patient or guardian.

After receipt of insurance benefits an itemized statement covering all services rendered will be mailed reflecting the amount currently due, if any. A copy of your insurance company’s Explanation of Benefits (EOB) will be included to explain your balance due.

If your insurance has changed, please call us prior to your appointment and bring your new insurance card with you.

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Cancellation Policy
Scheduled appointments are for the benefit of both the patient and the doctor and are RESERVED EXCLUSIVELY for you. It allows patients to be seen quickly and efficiently, to maintain an effective flow of the doctor’s schedule, and also allows the doctor to spend quality time with each patient.

• We must be notified 24 hours in advance of any schedule change to your appointment. 
• Tardiness of more than 10 minutes may constitute loss of an appointment.
• Failure to notify our office 24 hours in advance of a schedule change or No Showing for an appointment will result in a cancellation charge of $25.00.

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New Patient Appointment

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Scheduling Appointment

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Pre-Op instructions for Sedation Dentistry

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Post-Op Instructions

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Patient Education

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