Office Guidelines

We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our office policies.


  1. Balances remaining beyond 60 days from first billing will accrue interest at a rate of 1.5% per month on the unpaid balance. (18% annually)
  2. There will be a $35.00 fee charged to your account for all returned checks.
  3. In the event of default, I promise to pay legal interest on the indebtedness, collection costs, and related attorney fees.
  4. There is a minimum of $25 charged for broken/cancelled appointments without a 48 hr notice.


  1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
  2. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of these services.
  3. We will help prepare your insurance forms and assist in making collections from insurance companies.
  4. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We cannot render services on the assumption that our charges will be paid by the insurance company.
  5. Once the claim has been cleared by our office, for whatever reason, the balance is your responsibility.


  1. Cash or Check: We are happy to offer a 5% courtesy for treatment that exceeds $500.00 and is paid in full by check or cash at time of treatment. Not available to patients who participate with any in-network dental plan.
  2. We will also offer a 3% courtesy if treatment of $500.00 is paid by credit/debit card at the time of service. Not available to patients who participate with any in-network dental insurance.
  3. Optional Payment Plan: If multiple appointments are required, you may pay half of your portion due at the start of treatment and the balance upon completion.
  4. Monthly Payment Plan: An administrative staff member can help you with this option. A down payment is required when treatment is started, then monthly payments will automatically be charged to your credit/debit card until your balance is paid in full.
  5. Interest free arrangements are available for long term financing upon approval. Applications are available & can be processed while you are in the office.

CONSENT: (For patient & minor)

  1. I authorize this office to obtain x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis on myself or my dependents.
  2. I will be given the opportunity to discuss my treatment plan (or that of my dependents) with the doctor and financial arrangements will be agreed upon before treatment is started.
  3. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
  4. I hereby give Bell Dental Group and any employees and/or agents of BDG the right & permission to use and/or publish photographs of me for promotional & educational purposes (including, but not limited to, advertising, publicity, commercial or display of use). I release BDG of any liability from the production of published images.


My signature will authorize assignment of insurance benefits to this office. By signing this form, I confirm that I have read & understand the Office Guidelines of Bell Dental Group.