John B. Dale, D.M.D., M.S., P.C

John B. Dale, D.M.D., M.S., P.C.

Nisha Mehta, D.D.S., M.S.

Specialist in Endodontics

7314 North Willowlake Ct., Suite A

Peoria, IL 61614

Financial Policy

Patient’s Name ______

The following information is made to acquaint you with our financial policy:

Patients with Dental Insurance

It is very important that you be aware of your insurance coverage, including coverage percentages, deductibles and yearly maximums. Keep in mind that your insurance plan is a contract between you and your insurance company. For your convenience, we will contact your insurance company to determine estimated out of network coverage for services rendered. Please be prepared to pay, at the time of service, the entire portion not covered by your insurance. All Delta Dental patients are required to pay in full at the time of service. Delta Dental sends all claim correspondence directly to the patient.

We will be happy to submit a claim for you, but filing an insurance claim does not relieve you of responsibility for your bill. If payment from your insurance is not received within 60 days of service, your balance is then due in full and is your obligation. We take no responsibility for coverage denials by dental or medical plans.

Our practice is committed to providing the best treatment possible for our patients and we charge what is usual and customary for our area, regardless of any insurance company’s arbitrary determination for “usual and customary” fees.

Patients without Dental Insurance

For those without dental insurance, we require the full fee at the time of service. We accept cash, check, Visa, Mastercard, Discover and American Express.

Patients who are minors

Minors must be accompanied by a parent or legal guardian responsible for payment. Third parties will not be billed.

Fees for frequent procedures

Non-Surgical Root Canal Therapy Surgical Root Canal Therapy (Apicoectomy)

Molar $1450.00 Molar $1550.00

Premolar $1100.00 Premolar $1250.00

Anterior $975.00 Anterior $1025.00

Retrograde filling $250.00

Retreatment

Molar $1700.00 Consultation $150.00

Premolar $1350.00 Emergency Visit $175.00

Anterior $1100.00 Incomplete Root Canal $400.00

I, the undersigned, have read and understand the above financial policy and accept full responsibility for the charges incurred by me or my dependents for services rendered by John B. Dale, D.M.D., M.S., or Nisha Mehta, D.D.S., M.S.

Should it be necessary to enforce the provisions of this agreement through an attorney or by legal proceedings, the undersigned promises to pay all costs of collection, including reasonable attorney’s fees and all court costs.

______

Signature Relationship Date