Financial Agreement

Bryan P. Cioffari, D.D.S.
FINANCIAL AGREEMENT

Dear Patient:

Thank you for choosing Bryan P. Cioffari, D.D.S. as your dental provider. The following is our Financial Policy, which will help you with your concerns regarding our billing and payment procedures.

Payment for services is due at the time service is rendered. We accept cash, checks, money orders, debit cards, Visa, Discover, American Express, and Care Credit. We will submit an insurance claim on your behalf. If your carrier is not contracted with our practice, we will courtesy bill them with the understanding that, whatever the insurance does not pay, is then your responsibility to pay.

You are responsible for knowing your insurance benefits. What are the covered services in your plan? Does your Dentist participate in the plan? Patients are responsible for deductible, co-insurance and non-covered amounts at the time of service. Any billed balances are due within 30 days of the statement date.

Please have ALL INSURANCE CARDS and a PHOTO ID AVAILABLE FOR PHOTOCOPYING AT ALL TIMES. Any change of insurance, address, phone number, or emergency contact should be reported immediately.

Remember that insurance preauthorizations for services do NOT guarantee payment. If your insurance does not pay in full, we ask that you contact them, as charges will then be transferred to you. Interest on past due balances will accrue. There will be a $25.00 fee for all returned check items. Should your account become delinquent and be referred to a collection agency, you shall be financially responsible for the costs of the collection and/or legal fees.