Lyman Family Dentistry

Office Financial Policies & Assignment of Insurance Benefits

PAYMENTS for services are due at time of treatment.

Insurance: As a courtesy to our patients we will provide an estimate of your insurance coverage & benefits. We will also file your insurance claims and accept payment directly from the insurance companies for the covered portion of your treatment. All co-pays, deductibles, and patient portion of payments are due the day of service. Any account balances remaining due to declined insurance coverage or limitations by insurance will be billed immediately upon receiving the insurance benefits statement. This balance will also be due within 10 days after receiving statement.

Patient Financing: Payment options include; Cash, Check, Debit, Visa, MasterCard, Discover, American Express, and longer term financing is available through CareCredit for some treatments.

Exams: Treatment cannot be provided without proper evaluation and examination of your condition, therefore examinations are required for all new patients, including emergency patients. This will be in addition to any fees for other services provided such as extractions, fillings, etc.

X-Rays: Appropriate radiographs (x-rays) are required for the Doctor to properly diagnose and evaluate the patient’s dental condition. We make all efforts to control costs to our patients, but when needed, x-rays must be taken in order to provide the best quality dental care for our patients.

Appointment Rescheduling: We reserve our appointment times especially for our patients on an individual basis, and we strive to accommodate your schedule. Since we make arrangements to reserve our dental treatment rooms especially for your appointment, we must ask that you give a minimum of 48 hour notice in order to change or reschedule your appointment time. If you cancel or break your appointment without adequate notice, our office reserves the right to charge a broken appointment fee of $30.

Returned Check Fees: Personal checks are accepted for any services, but due to bank fees, our office charges a $30 fee for any bounced or returned checks. After a returned check, we must also ask that you make your payments in the form of cash or credit card.

Prescriptions called in to pharmacy: Prescription medications cannot be written for a patient that has not had an examination by the Doctor. Also, in the case where a regular patient of record requires a prescription “called in” to a pharmacy there will be a fee of $20.

**By Signing a copy of the Financial Policy Statement, the patient understands all the policies stated above and also agrees to allow assignment of dental insurance benefits and payments be made directly to our office.

Please click link below to print and sign form.
Office Financial Policies & Assignment of Insurance Benefits