Making your lives easier makes our practice better.

Below you'll find some downloadable forms and other helpful documents. You must have the latest version of Adobe reader to open these forms. If you don't, no sweat—simply download it here.

Forms

pdf-iconDownload New Patient Registration Form

pdf-iconDownload New Patient Medical History Form

pdf-iconDownload Authorization for Record Release Form

pdf-iconDownload Financial Policy Brief

pdf-iconNotice of Privacy Practices (HIPAA)

Financial Policy

Our primary goal is not to allow the cost of treatment to prevent you from benefiting from the quality care you need or desire. In our office, we strive to maximize your insurance benefits and make any remaining balance easily affordable.

Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We charge what is the usual and customary for our area. We will assist you with your benefit eligibility before treatment to help you calculate your costs and maximize your insurance. We will be sensitive to your financial circumstances and do everything possible to help you achieve oral health.

Ultimately, however, You are responsible for payment regardless of any insurance companies arbitrary determination of usual and customary rates.
We are happy to submit the claims necessary to see that you receive the full benefits of your coverage; however we cannot guarantee any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy by electronically filing your claim the day of your appointment. Your insurance company will reimburse you directly in a timely manner. If there are any complications, we will assist you with any information you may need.

We accept the following forms of payment: Cash, Check, Visa and MasterCard. We offer a 5% discount for all treatment over $2000 paid in cash or check. In addition, we offer CareCredit, a patient payment program offering a full range of No Interest and Extended Payment Plans for treatment fees from $1 and up.

Payment for services is due at the time services are rendered unless prior arrangements have been made. Checks that are returned to our office from your financial institution are subject to a $25.00 returned check fee. This fee covers the processing fees that are charged to our office.
We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Most often, financial misunderstandings can be managed with a phone call. Please feel free to contact our wonderful staff at anytime to discuss any concerns you may have.

Thank you for understanding our Financial Policy.

Deposit Policy

Due to the extensive amount of time our staff and doctors devote to preparing and reserving uninterrupted time for reservations over 2 hours, we require a deposit of half of the treatment fee to make your reservation.

Rescheduling / Change in Schedule Policy

Our practice is dedicated to quality care and exceptional service. Our doctors and team spend extensive amounts of time preparing for your visit. Broken and missed appointments create scheduling problems for our team as well as other clients. If you find that you must change your appointment, we require a minimum of 48 hours notice so that we may make every effort to accommodate other clients.

If proper notice is not received, a fee of $50.00 will be charged for every hour of allotted time cancelled to your credit card on file. I have read and agree to the Financial Policy and the Cancellation Policy of Renaissance Dental Center. I agree to a credit card on file that may be charged for violation of these policies or upon my approval for services rendered.