Financial Policy Form

Insurance - Please remember that your insurance is a contract between you and your insurance company. We are not a party to that contract. It is your responsibility to inform the office of any insurance changes prior to being seen. Failure to provide the office with correct or updated insurance for billing may result in all charges becoming your financial responsibility. As a courtesy to you, our office provides certain services, including pre-treatment estimates and billing. It is physically impossible for us to have the 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 insurance plan has as well as making sure Dr. Elias is a preferred provider. Please be aware that some or perhaps all the services provided may or may not be covered by your insurance policy/plan. Any balance is your responsibility whether your insurance plan pays any portion

Payment - Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for all professional services rendered. Pre-treatment estimates are not a guarantee of payment.

Full Payment is due at time of service. If insurance benefits apply, ESTIMATED patient co-payments and deductibles are due at the time of service, unless other arrangements have been made and agreed upon. ESTIMATES are subject to change at any given time.

Unpaid Balances must be paid in full prior to being seen for future appointments. Treatment and or routine prevention will not be rendered if there is a balance on the account.

Missed Appointments

Unless we receive notice of cancellation 24 hours in advance, you will be charged $50. Missed or no-showed appointment fees must be paid prior to rescheduling. Please help us maintain the highest quality of care by keeping your scheduled appointments.

I have read, understand and agree to the terms and conditions of this Financial Agreement.