Our Financial Policy

We are committed to providing you with the best possible care. We are happy to discuss our professional fees with you at any time. Please ask if you have any questions about our fees, financial policy or your payment responsibility.

All patients must complete in full our "Patient Information Form" before seeing the doctor. If you have insurance please provide us with both your dental and medical insurance cards and sign the appropriate insurance claim forms.

Payment

If you do not have insurance it is your responsibility to pay in full at the time services are rendered. If you do have insurance it is your responsibility to pay the deductible and /or co-payments, as applicable, at the time that services are rendered. We accept Cash, Checks and Credit Cards.

Insurance

INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. It is your responsibilities to confirm with your insurance company that Dr. Tamimi is a participating provider under the terms of your plan to have an insurance representative explain your benefits. We will call your insurance company for estimated itemized of your benefits. The approximation of fees, benefits to be paid and your co-payment or deductible is simply an estimate. This is never a guarantee of benefits. Therefore, when an "Explanation of Benefits" is received from your insurance company, it may differ from the estimate provided. It is the patient's obligation to pay any balance due. We will handle your claim according to the agreement with your insurance and as a courtesy to our patients; we will file your insurance claim.

College Students

Insurance companies require evidence that a college student is full-time for the current semester or upcoming semester. We will accept the following types of proof: a copy of your current registration, a recent invoice showing full-time status or certification or full-time status on school letterhead. An up-to date student ID may be acceptable if it identifies that the student is full-time and if our services rendered during the current semester. On mid-semester breaks and during summer months, a student ID will not be acceptable proof.

YOU ARE RESPONSIBLE FOR TIMELY PAYMENT OF YOUR ACCOUNT. A $10.00 REPEAT BELLING CHARGE WILL BE ADDED EACH MONTH ON UNPAID BALANCES PAST 30 DAYS.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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