Financial Form

  • MOUNTAIN PARK DENTISTRY Dr. Mow D.D.S.

    FINANCIAL POLICY

    In our continued efforts to provide you with the best dental care possible and to provide our services at reasonable rates, we are pleased to offer the following methods of payments:

    I. Cash or Check
    2. Visa, MC, and Discover
    3. Extended payment plan through financing deferred interest.(O.A.C.) Care Credit

    PATIENT LIABILITY

    • Entire cost of dental treatment
    • Deductibles and your portion according to your insurance coverage

    Insurance is a contract between you, your insurance company, and your employer. As a courtesy, we will bill your insurance after coverage has been verified. However, deductibles and co-insurance amounts are due at the time of treatment. We cannot guarantee your insurance coverage. We will give you an estimate only on the treatment that is diagnosed.

    We are happy to accept assignment of insurance benefits. Any patient balance that is not paid within 60 days, will be subject to interest and late fees.

    There will be a $25.00 service charge on returned checks.

    24 Hour Notice is required if unable to keep appointed time. We do assess a $50.00 cancellation fee for less than 24 hour notice.

    If you have any questions regarding your bill, please ask or call our office at 480-759-9300.

    I have read, understand and agree to the above Financial Policy. I am aware that I am fully responsible for all costs regardless of insurance coverage. In the event that your account is not paid in full, the balance may be to reported to our collection agency, reported to the IRS as stated in the IRS code Section 61(a)(12) as taxable income or a small/ civil claim can be filed against you. Should legal action be necessary to collect the account, I/We agree to pay all fees incurred while trying to collect on this account.