Financial PolicyConsent(Required) I agree to the financial policy.Patients with Insurance Coverage: We will be glad to help you obtain the appropriate benefits from your insurance carrier and bill your carrier as a courtesy to you. However you are responsible for the payments of the account. We will be happy to request a pre-estimate of benefits from your insurance carrier if you request us to do so. Routine treatment is generally preferred without submitting a request for the pre-estimate of benefits. Portions of the bill may not be paid by the insurance company and are to be paid by the patient. Sometimes there is a co-payment required by you at the time of your visit, per your agreement with your insurance carrier. Even if you have a deductible coverage (this is possible if you and your spouse both have insurance), there may still be a problem that will be your responsibility. If you are having treatment over a period of time, we appreciate your payment during the course of the treatment. Our receptionist will be more than happy to help you set up a payment plan. Patients without Insurance Coverage: Patients without insurance coverage are requested to pay for services as rendered. Additional Terms: Appointments canceled within less than 24 hour notice are subject to a $25.00 cancelation charge. Checks returned by your bank are subject to a $20.00 processing fee. Accounts unpaid after 30 days from the billing date are subject to a finance collection. You will be responsible for collection costs in the amount of 30% of the outstanding balance, together with court costs and reasonable attorney’s fees. We would like to take this opportunity to welcome you to our office and assure you that we will do our best to provide you with the best care possible.Name(Required) First Last Signature of patient or guardian(Required)Today's date(Required) Month Day YearCAPTCHA Call Today+1 (610) 631-3338Fax: +1 (610) 631-03133125 Ridge Pike, Suite BEagleville, Pa 19403Schedule Now