It is customary to pay for all dental treatment at the time of your visit. Any other arrangements must be made in advance.

You may pay your portion at the time of your visit using cash, check, Visa, MasterCard, Discover or American Express, including HSA and FSA accounts.
Arrangements may be made in advance for interest free financing through Care Credit.
For those patients who have insurance benefits, we will estimate the portion we anticipate is not covered by insurance and will inform you of your expected co-payment that is due when services are rendered.
Please keep in mind these are not guarantees of your insurance payment but estimates only.
You may set up automatic credit card payments for pre-arranged installment plans.
A statement fee of $5.00 will be applied monthly for accounts not paid in full.

I assign all dental insurance benefits to which I am entitled to the extent permitted under my dental insurance to the dentist.
This form also authorizes this practice to submit insurance claims and receive payment directly from the insurance carrier with the notation “SIGNATURE ON FILE.”
I agree to be responsible for payment of all services rendered to me or my dependents.

I have read and agree to the Weaver, Reckner & Reinhart Dental Associates Financial Policy