Payment & Financial Policy

Our practice has providers who participate in the following insurers:

Community Health Options
Harvard Pilgrim
Medicaid of NH
Self Pay
United Healthcare

Fees for our professional services are due and payable at the time of Service. However, if you have coverage with one of the above companies, you may be required to pay only the deductible, co-pay, or non-covered service fee at the time of service.

If you have coverage with another company a minimum of 30% payment may be expected at the time of service. We will gladly submit a claim for services to your insurance for the total
charges. Any overpayment by the patient will be reimbursed to the patient. Any remaining
balances will be billed to the patient and must be paid within 60 days of treatment unless prior arrangements have been made.

If you are not covered by insurance, you will be considered a self -pay patient. As a self-pay
patient, our fee(s) is expected to be paid in full at the time of service. A minimum of $100
deposit is due at the time of check-in .. A courtesy discount of 10% will be applied to the balance if paid in full at the time of the visit.

In the event your account becomes delinquent, you will be responsible for collection fees,
attorney fees, and court costs in addition to your bill.

There is a $25.00 charge for returned checks. If a check is returned and not redeemed within 21 days, action will be taken for collection.

Marital status is NOT a consideration under any circumstance. Decree of custody or lack
thereof does NOT alter financial responsibility. The parent accompanying the child on the day of service will be the financial responsible party. We will gladly provide you with copies of
statements which you may need to provide to the other parent for reimbursement.

If you have any questions or need assistance regarding our policy, please contact the billing
staff as soon as possible. Financial arrangements should be made before any surgical
treatment is rendered.

For your convenience, we accept CASH, CHECK, VISA or MASTERCARD.

Click HERE to download this form, then print, sign, and bring into the office at your first visit.