We realize that every person’s financial situation is different. For this reason, we have worked very hard to
provide a variety of payment options to help you receive the dental care you need to enjoy a healthy and confident
We are happy to file the forms necessary to see that you receive the full benefits of your coverage; however, we
cannot guarantee coverage. Unless prior arrangements are made, you will be expected to pay your portion as
services are provided. Please keep in mind that we can only estimate your portion. If there is a difference
after your insurance company has paid, it is your responsibility to pay the difference. Because the insurance
policy is a contract between you and the insurance company, we will not enter into a dispute with your insurance
company over your claim. We will provide information to support the necessity for treatment, which may assist
you in recovering your benefits. Any balances not paid by the insurance company within 60 days of submission
become the patient’s responsibility to pay at that time.
Senior Discount: We are able to offer a 5% senior discount for ages 63 and older to patients who pay their
portion in full at the time of service.
Cash or check: We are able to offer a 5% pre-payment courtesy for treatment that exceeds $750.00 and paid in
full prior to treatment. (May not be used with senior discount)
Credit Card: For your convenience, we have made arrangements to accept payment by several major credit
cards as well as bank debit cards. A 3% discount is offered if patient portion of treatment exceeds $750.00 and is
paid in full prior to treatment. (May not be used with senior discount)
Financing: Upon approval, we offer interest-free financing through CitiHealth or Care Credit. Applications are
available and can be processed quickly.
- Delinquent accounts may be subject to a $20 late fee.
- There is a $40.00 charge for all returned checks and declined auto debit/credit card payments on due date.
- Credit History may be checked.
- In the event of default, I promise to pay legal interest on the indebtedness, collection cost of up to 50% of
the balance, and related attorneys’ fees.
- There may be a $50.00/hour charge for broken/cancelled appointments not allowing 24-hour notice.
- The person who accompanies the minor child will be responsible for payment.
I authorize the doctor to obtain x-rays, study models, photographs, or any other diagnostic aids deemed
appropriate to make a thorough diagnosis. I will be given the opportunity to discuss my treatment plan and make
financial arrangements before treatment is begun.
If care is being rendered on a minor child, I authorize the doctor to obtain x-rays, and to treat my child as needed.
I understand I will be given the opportunity to discuss the treatment with the doctor and that the parent or
guardian who accompanies the child to the office is responsible for payment.
I assign dental benefit payment to be paid directly to Milford Dental Excellence from my insurance company.