Thank you for choosing Amelia East Family Dentistry, Inc. as your dental care provider. We are committed to your
treatment being successful. The following is a statement of our Financial Policy, which we require you read and sign
prior to any treatment. All patients must complete our Information and Insurance form before seeing the dentist.
Payment of all insurance co pays and deductibles are due at the time of service.
We accept CASH, CHECKS, VISA, MASTERCARD, DISCOVER, and AMERICAN EXPRESS.
We offer EXTENDED PAYMENT PLANS with prior credit approval.
Payment for non insurance patients is due at the time of service unless PRIOR arrangements have been made with
the Office Manager.
The balance is your responsibility whether your insurance pays or not. We cannot bill your insurance company unless
you give us your insurance information and an original claim form or insurance card. Your insurance policy is
contracted between you and your insurance company. We are not a party to that contract, in most cases. We will bill
your insurance company as a courtesy to you. Although we may estimate what your insurance may pay, it is the
insurance company that makes the final determination of your eligibility. You agree to pay any portion of the
charges nor covered by insurance. Please be aware that some, and perhaps all, of the services provided may
be non covered services and may not be considered reasonable and customary under your dental insurance policy. Our
practice is committed to providing the best treatment for our patients and we charge what is usual and customary in
our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and
An adult must accompany minors to all appointments. The adult accompanying a minor and the parents or guardians are
responsible for full payment of the minor's balance. Non-emergency treatment will be denied to any minor that is not
accompanied by an adult.
All balances billed shall be paid in full at the first billing. There may be a re-billing fee for each additional
billing cycle thereafter. If your account becomes past due, we will not be able to continue treatment until the
balance is paid in full. If your account becomes past due, we will take the necessary steps to collect this debt. If
we have to refer your account to a collections agency or lawyer, you agree to pay all collection costs and attorney
fees. You understand if this account is referred to a collection agency or lawyer or if your past due balance is
reported to a credit reporting agency, the fact that you received treatment at our office becomes a matter of public
record. All returned checks will be collected by a collection agency and there will be fees associated with the
You will need to request, in writing, and pay a reasonable copying fee if you want to have copies of your records
sent to another doctor or organization. You authorize us to include all relevant information, including your payment
history. If you are requesting your records to be transferred from another doctor or organization to us, you
authorize us to receive all relevant information, including your payment history.
Unless cancelled at least 24 hours in advance, there will be a $40 charge for all missed appointments. This fee must
be paid before a new appointment is scheduled. For the convenience of our patients, we offer some evening and early
morning appointments. Due to the high demand for these appointments, they are considered prime time appointments. If
you do not cancel these appointments at least 24 hours in advance, we will bill the missed appointment charge and we
will no longer be able to schedule you for a prime time appointment. Patients with three or more missed appointments
will be asked to transfer their records to another doctor. Please help us serve you better by keeping all scheduled
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.