New Patient Packet

Step 5 — Financial Responsibility Awareness

Masci & Hale Advanced Aesthetic and Restorative Dentistry is a Fee for Service, Out of Network (non-insurance participating) Practice. This means that we are not contracted with any dental insurance companies and do not accept insurance payments as full coverage for procedures. We will do all the necessary paperwork & claim submissions for you.

As a courtesy to our patients with insurance plans that are willing to send our office their payment directly, we will accept that insurance check as the initial payment and then bill our patient for any remaining balance. If they cover our fee in full, you will not be billed for any balance.

A credit card can be left on file ahead of time for automatic payment of any out of pocket balances.

There are some insurance companies that will not send us their payment directly. They will however reimburse the patient if it's a PPO policy. For patients with these plans, you will be responsible for full fees at time of service unless other payment arrangements have been agreed upon.

By signing below, you agree that you fully understand our office financial policy and are aware that you will be responsible for any/all fees remaining after your insurance has paid their allowable portion.

Financial Responsibility Awareness Signature *

Date *