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Dental Group of Millburn, P.A.

Financial Policy

We at Dental Group of Millburn, P.A., are pleased you chose us to facilitate and care for your dental health needs. As in the past, we require payments are made at time of service. For those patients who have financial assistance from insurance, the estimated co-payment is due at this time.

We accept MasterCard, Visa, American Express, Discover and Care Credit, as well as cash or personal checks. In a few instances, we are able to offer financial arrangements. We'll be happy to discuss these options with you if the situation applies.

Emergency Patients:

For emergency patients who are not patients of record, we will file any insurance claims, as long as we can verify your benefits. If we are unable to verify these benefits, we will require payment in full.

Minors with two separated or divorced parents:

When two parents are each responsible for one half of the cost of the children's dental care, the parent who brings in the child is responsible for paying the co-payment or full fee. They will also be responsible for collecting payment from the other parent.

NSF/ Returned Checks:

There is a $25.00 fee for processing a returned or NSF check. We reserve the right to reject check payments once a returned or NSF check occurs.

Short Notice Cancellations, Broken Appointments or Disconnected Numbers:

Each appointment is a reserved time for you and only you. Each time you do not keep your appointment; other patients who do keep their appointments are penalized. Although we do not like to charge for broken appointments, no-show or short notice cancellations, we do reserve the right to refuse to schedule more appointments unless paid in full before service is commenced and/or charge a $50.00 fee. Also, if the phone number we have on file for you is disconnected, leaving us no alternative number to reach you by, we will cancel your appointment and reserve the right to not reappoint your appointment.


Many times a deposit is required. This varies by length of appointment or complexity of procedure you require, we will notify you if a deposit is needed.

I have read and understand the financial policies of Dental Group of Millburn, P.A. I understand that I am ultimately responsible for all fees incurred for my dental treatment. (This agreement will apply to any and all accounts in which I am the responsible party. A copy will be placed in those charts as well as my own.)

I also understand that since insurance plans are payment assistance plans, they are not designed to cover the entire costs of treatment. I understand that my dental insurance carrier may pay less than the bill for services. If the insurance claim(s) is not paid in 60 days, the balance will become my responsibility. By signing this form, I have authorized assignment of benefits directly to the practice.

Most insurance companies are now "deciding" which type of restorative filling the patient should receive, regardless of the clinical inclination. While this office does everything possible to maximize the insurance benefits, I am aware that Dental Group of Millburn, P.A., will diagnose the type of restorative filling that is needed due to their Standard of Care, not what the insurance company decides. This will mean for some patients, based on the insurance company's benefit plan, composite resin (tooth colored) fillings on posterior teeth will only be reimbursed at the amalgam (metal) filling rate, with the remainder of the fee due from the patient.

I am also aware that the office reserves the right to charge 1.5% interest for any balance over 90 days old, as well as, any and all additional charges that might occur if the account is turned over for collection and/or if attorney services are required.


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.

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.