Financial Policy Agreement, Cancellation/No Show Policy, Assignment of Benefits, General Authorizations

Thank you for choosing Verardi Dental as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health.

Please read carefully and sign below. You may request a copy.

Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, American Express and Discover. Outside financing is available through Care Credit upon approval.

Cancellation & No Show Policy: Rescheduling must be given 24 hours before the appointment time. You may be rescheduled if you are more than 10 minutes late and you will be charged a $50 cancellation fee if you do not show for your scheduled appointment or if you cancel within 24 hours of your appointment. If you fail to keep more than 2 appointments without advance notification, you may be restricted to a walk in or time available basis.

As a courtesy to you, we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you. However it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. 

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract. 

At Verardi Dental we are committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. 

We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payments directly to Verardi Dental. 

Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.

We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim. 

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.

Name *
Date *
I authorize the following person to have access to my dental information:
I authorize the following person to have access to my dental information: