Payment for services, including deductibles and copayments, are due at the time of the
service unless other arrangements have been made prior to treatment. Payments may be
made using cash, check, or credit cards. Any arrangements for third-party financing must
be made before starting treatment. North Cypress Dental accepts most dental benefit
plans, however it is the patient’s responsibility to understand their insurance plan’s terms and
conditions, including the providers Network status with their plan.
The dental benefit contract is an agreement between you and the dental benefit company.
You are ultimately responsible for all charges. We cannot guarantee that any coverage
estimated by your plan will be paid once a claim is filed. To maximize your benefits and
because plans differ from carrier to carrier, and from policy to policy, our office may refer
you to your carrier or your employer’s benefits coordinator for assistance in understanding
your plan. Please note that your dental plan is intended to cover some but not all dental
care costs, and not all services are covered by your plan. You are responsible for payment
of all services regardless of the payable benefit. Checks that are returned to our office from
your financial institution are subject to a $50 returned check fee. This fee covers the
processing fees that are charged to our office. We would be happy to discuss our charges
and how they relate to your particular situation.
CANCELLATION/ NO SHOW POLICY
Our office requires patients to provide at least 24 hours’ notice when canceling or rescheduling an
appointment. We reserve your appointment time specifically for you and we understand
unanticipated events happen; however, if you are extremely late, no-show or cancel short notice, that
is a lost opportunity to another patient who could have taken that time to be seen by our office.
IT IS THE PATIENTS RESPONSIBILTY TO REPLY TO CONFIRMATIONS, WHETHER IT IS VIA
TEXT, EMAIL, OR A PHONE CALL NO LATER THAN 48HRS BEFORETHE SCHEDULED APPT.
FAILURE TO DO SO WILL RESULT IN YOUR APPOINTMENT BEING AUTOMATICALLY
CANCELED.
Cancellations -When cancelling any appointment, it is required to give at least one full business
days’ notice. This allows the opportunity for someone else to schedule an appointment. If you are
unable to give us one full business days’ notice, there will be a $30 charge made to your account.
This amount must be paid prior to your next appointment.
No-Shows- Anyone who either forgets or consciously chooses to forgo their appointment for
whatever reason will be considered a "No-Show" and will be charge a fee of $30 for the missed
appointment. This amount must be paid prior to your next appointment.
Late Arrivals : We have a 10minute grace period. If you are running a few minutes late for your
appointment, we ask that you call our office so we can inform your provider to then determine your
appointment status. If you are 15 minutes or more late to your appointment your appointment will be
forfeited and you will have to reschedule in order to accommodate other patients whose appointment follow yours.
Out of respect and consideration to your doctor and other patients please plan accordingly and be on time. Thank you for your cooperation.
Please indicate your understanding and acceptance of these financial policies by signing below.
Patient Name: ____________________________
Patient, guardian or guarantor signature: _______________________________ Date___________
