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Financial and Office Policy

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St. Helen Family Dentistry

Steven R. Tozer, D.D.S.
631 N. St. Helen Rd, PO Box 9
St. Helen, MI 48656

Financial And Office Policy

Thank you for choosing us to be your dental health care provider. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our office and financial policy, which we require that you read, agree to, and sign prior to treatment.

All patients must complete and sign our "Patient Medical History" prior to treatment.

  1. Payment is Due at time of service
    We accept cash, checks, Visa, Master Card and Discover. Account balances past 60 days will incur interest at a rate of 1.9% per month (22.8%).
  2. Insurance
    We accept most insurance benefits. By signing our financial policy, you agree to assign dental benefits to Dr. Steven Tozer. We also require your co-pay and deductible to be paid at the time of the treatment. All fees not paid by the insurance company are the responsibility of the patient or subscriber of the policy. Your insurance policy is a contract between you and your insurance company. Please be familiar with your coverage. We are not a party to that contract.
  3. Minors
    An adult (parent or legal guardian or other designee) MUST accompany a minor child (under age 18) for all treatment. The parent (or legal guardian) is responsible for full payment. If the minor receives insurance benefits from a non-custodial parent, we will bill that insurance for payment. The custodial parent will be responsible for any outstanding balance.
  4. Failed Appointments
    We confirm your appointment by telephone, but we are not always able to reach you. If we are unsuccessful, YOU must call us to confirm your appointment at least 24 hours in advance. That time has been reserved especially for you. If you need to change your appointment, we require at least a 24-hour notice. If you fail to notify us at least 24 hours in advance, a fee of up to $50.00 will be charged to you. Also, if you fail to keep an appointment without notification, we can cease providing further treatment.

Thank you for reading our financial and office policy. Please let us know if you have any questions or concerns.

I have read, understand and agree to the above financial policy.

SIGNATURE ___________________________________________________________