We accept all dental insurances and verify insurance benefits prior to your appointment. Before your appointment, our office will contact you to confirm your appointment and review your out-of-pocket estimate.
Patient Financial Agreement Forms
Delta Dental
If you do not have health insurance or plan to pay for dental services and procedures yourself, under the law, you have the right to receive an estimate of your bill for healthcare items and services prior to those items being provided. This is called a Good Faith Estimate.
A Good Faith Estimate shows the total expected cost of any health care items or services. The estimate is based on information known to the provider at the time the estimate is created. The Good Faith Estimate does not include any unknown or unexpected costs that may be added during your treatment.
This estimate is not a contract and does not require you to obtain the services at this office. The Good Faith Estimate may not include additional items that may be recommended for post treatment care or rehab services.
Providers and facilities must give you the Good Faith Estimate if you schedule an item or service at least 3 business days before the date you are scheduled to receive the item or service. Secondly, the provider must give you a Good Faith Estimate no later than 1 business day after scheduling.
If you schedule the item or service or ask for cost information about it at least 10 business days before the date you get the item or service, the provider or facility must give you a Good Faith Estimate no later than 3 business days after you schedule or ask for the estimate. The GFE should include a list of each item or service and the health or dental service code along with the total estimated cost.
The Good Faith Estimate must be provided in an accessible format in compliance with nondiscrimination laws. Providers and facilities must also explain the Good Faith Estimate to you over the phone or in person if you ask, then follow up with a written (paper or electronic) estimate, per your preferred form of communication.
If you receive a bill for an amount that is at least $400 or more than your Good Faith Estimate from that provider or facility, you can dispute the bill.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
