Insurance Filing

You are financially responsible for all charges whether or not paid by insurance. As a courtesy to you, we will submit your dental claim. Our office can only be responsible for giving you an estimate of what your co-pay will be. That co-pay will be due the day treatment is performed. In the case that there is a remaining balance after the insurance company has paid, or if they do not pay at all, that balance will be due and payable from you immediately. Each insurance policy is unique and we urge you to contact your employer's human resource department or insurance company for an explanation and accounting of your benefits.

Notice of Privacy Practices

We are required by law to maintain the privacy of, and provide individuals with notice of our legal duties and privacy practices with respect to protected health information. Signature is only acknowledgement that you have received our Notice of Privacy Practices.

Missed Appointments

Missed appointments are a contributing factor to the rising cost of healthcare. We require a 24 hour notice to change an appointment time. We cannot accept cancellations from the answering machine left within 24 hours prior to your appointment. If an emergency should arise and you are unable to reach our office in the time allotted please contact Dr. Dougherty at (602) 432-6277. There will be a $100 charge assessed to your account should the required notice not be given.

Delinquent Accounts

Should any account become delinquent (60 days or older), I understand that interest charges may be assessed at the rate of 18% APR. I also understand that if my account is turned over to a collection agency I will incur collection costs (30%) and attorney fees, and will be added to my balance. Returned checks will be assessed a $25 non-sufficient funds charge.