Thank you for choosing us as your dental care provider. We are committed to delivering the highest quality care in a transparent and respectful manner. Please review the following policy carefully.

Payment Policy:

• Full payment is due at the time services are rendered.
• Acceptable payment methods:
  • Credit Cards: Visa, MasterCard, American Express.
  • Debit Cards
  • Cash or Personal Checks
• Prepayment Discount: A 5% discount is available when full payment is made at least one week prior to your scheduled appointment.
• Returned Checks:
  • A $25 fee will be assessed for the first returned check.
  • A $35 fee may be charged for any subsequently returned check (CA Civil Code 1719).

Deposits for Services Over $500:

• A 50% deposit is required at the time of booking when treatment totals more than $500.
• This deposit is non-refundable if the appointment is cancelled or rescheduled with less than two (2) full business days' notice.

Insurance Information:

• Your dental insurance is contract between you and your Insurance company.
• You are financially responsible for all services provided by our office, regardless of insurance coverage or reimbursement.
• As a courtesy, we will:
  • Submit a pre-treatment estimate upon request.
  • Submit claim electronically to your insurance provider.
  • Provide a claim form if you prefer to submit.
• If your insurance has not paid within 60 days, the outstanding balance becomes your responsibility and may be charged to your card on file with prior written authorization.
• Need help understanding your insurance benefits? Just ask, we are here to assist.

Missed or Late-Cancelled Appointments:

• We require at least two (2) full business days' notice to cancel or reschedule your appointment.
• Missed or late-cancelled appointments may result in a $50 fee, which will be charged to your account or credit card on file, with prior consent.

Minor Patients:

• The parent or legal guardian is financially responsible for treatment provided to a minor.
• If the party responsible is not present at the time of service, the credit card on file will be charged, as authorized in advance.

Credit Card Authorization:

By signing this agreement and completing the separate Credit Card Authorization Form, you authorize οι office to charge your card for the following, as applicable:

• Balances unpaid by your insurance after 60 days.
• Missed or late-cancellation fees
• Returned check fees.

Medical Debt Reporting Compliance (SB 1061-effective 7/1/25):

In compliance with CA SB 1061, we do not report medical debt to any consumer credit reporting agency:

A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. If such information is knowingly furnished, the debt shall be void and unenforceable.

Billing Disputes and Patient Rights:

We are committed to transparent billing. If you believe your bill contains an error or have any concerns, please contact our office within 30 days of receiving your statement. We will review and respond promptly to resolve any issues.

Language Assistance:

If you require this policy in another language, please notify our front desk. We are committed to serving the needs of our diverse patient community.

Acknowledgement and Agreement

I have read, understand, and agree to the terms outlined in this financial policy. I accept responsibility for all charges incurred and authorize the office to process payments as specified above. I understand that any legal action to collect unpaid balances will be based on this written and signed agreement, in compliance with California AB 1414.

Purpose Of Authorization

To streamline billing and ensure timely payment, we request your authorization to keep a credit card on file for use as outlined in our Financial Policy

Card information is stored securely in compliance with HIPAA and PCI-DSS security standards.

Authorization Of Use

I authorize the Palm Desert to charge my credit card for the following, as outlined in the Financial Policy:

• Balances unpaid by insurance after 60 days
• Missed or late-cancellation fees
• Retumed check fees
• Authorized payment plans for approved treatments

Charges will only be made under the terms of the signed Financial Policy. Receipts will be available upon request.

Authorization Duration

This authorization will remain in effect until I provide written notice to revoke it. I understand that revocation must be submitted in writing and may require up to five (5) business days to process.

Cardholder Acknowledgment

I acknowledge and agree to the terms stated above. I certify that I am the authorized user of the credit card listed above and will not dispute valid charges as described herein and in the associated Financial Policy.

Compliance Notice

• In accordance with California law, your card will not be charged without signed authorization.
• As required by SB 1061, this office does not report medical debt to any consumer credit reporting agency.
• In accordance with AB 1414, all collection actions will be based on signed, written agreements only.