BASIC POLICY : Payment for services rendered is due in full at the time of service. Our office accepts cash, personal checks, debit cards, and care credit. There is a $ 25.00 return check fee due and payable from you for each check returned to us by your bank.

FOR PATIENTS WITH INSURANCE : As a service to our patients  we will accept "assignment of benefits" and will bill your insurance carrier, provided proper information is provided to us. We will also assist you in billing your secondary insurance  carrier , if applicable , and in researching unpaid claims. Every effort will be made to closely  estimate your co-payments and deductibles which are due at the time of service . Ultimate responsibility for any unpaid  balance rest on you. Please understand that insurance is a contract between you and your insurance company. If an insurance carrier has not paid within 90 days of billing, any unpaid fees are due payable by you.

NON-COVERED CHARGES: Any charges not paid by your insurance carrier will require payment in full at the time services are provided  or upon notice of insurance claim denial. CANCELLATION OF APPOINTMENTS: Your appointment time has been reserved exclusively for you. In fairness to other patients and the doctor, we require 24 hour notice when cancelling an appointment. You will be charged a $50.00 fee for each cancelled appointment without a 24 hour notice of for failed appointments. This practice  reserves the right to dismiss patients with excessive cancelled or failed appointments.

ASSIGNMENT OF INSURANCE BENEFITS:  I hereby assign all dental and/or medical benefits, to which I am entitled ,private  insurance, and any other health plans to Dr. Mustafa Al Khayyat/ Discovery Dental. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered to be valid as the original.  I understand  that I am financially responsible for all the charges whether or not paid by my insurance carrier. I hereby authorize said assignee to release all the information necessary to secure payments.

HIPPA NOTICE  OF PRIVACY PRACTICES: We are required by law to maintain the privacy of, and provide individuals with notice of our legal duties and privacy practices with respect to protected health information .

If you have any objections, please speak with Dr. Al Khayyat.