Financial Agreement

Welcome to Just Smilez Dental. Thank you for choosing our office for your dental care needs.

This agreement is to inform you of your financial obligations to our practice. We are committed to providing you with the highest quality of care possible. This financial agreement is intended to facilitate our ability to provide you with excellent service while making you informed of our policies.

All charges you incur are your responsibility regardless of your insurance coverage. As a courtesy to you, we will process and submit your insurance claim(s). If, for any reason, your insurance company denies or fails to cover your claim, you are responsible for payment in full. It is very important that you provide our office with your most recent insurance information. Most insurance companies change policy number and plans frequently throughout the year.

Our office is out-of-network (non-participating) with ALL insurance companies other than Delta Dental PPO/Premier. We CAN NOT submit any claims to Medicaid, Medicare, Child Health Plus, Fidelis, Delta Care, or any other plan purchased through the NYS Marketplace Exchange.

Your estimated portion of treatment, which is the amount not covered by your insurance, is due  at the time service is provided. Your portion due, may be adjusted after the time of service depending on the payment made from your insurance company. Our office accepts cash, checks, credit cards and Care Credit.

Returned checks will receive a $25.00 fee placed on your account. All outstanding balances exceeding 60 days (excluding outstanding insurance claims) will be sent to our collection agency.

Our office requests that you give us at least a 24 hour notice to change or cancel your appointment. This notice will allow us to offer the appointment time to another patient on our call list.

Please do not hesitate to contact our office with any questions regarding this financial agreement. We are committed to providing you with exceptional care and a positive experience.

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Signature Certificate
Document name: Financial Agreement
lock iconUnique Document ID: 617ef3d38261b62177effbaa0fd65c514af379cb
Timestamp Audit
Feb 25, 2022 1:36 pm CSTFinancial Agreement Uploaded by Dr. Divya Sankepally - IP