Patient Financial Policy
Welcome to the office of Metro Dental Associates. We want to make your visit productive and enjoyable. We are happy
to answer any and all questions regarding insurance plans and payment policies.
Our Policy requires payment at the time of service for your visit.
If you are a member of a dental Insurance Plan and have chosen us as a provider of your care, it is your
responsibility to:
• Provide us with information relative to your claim, including insurance card, number, employer, birth date,
address and Social Security number. This information is requested on the Patient Registration form, which
we ask that you complete during your initial or subsequent visit.
• Pay your deductible or co-pay at the time of service.
• Pay for services not covered by your insurance carrier.
Insurance claims for your carriers are filed as a courtesy at no charge to you.
• To assist you with your payment, our office accepts Visa, Mastercard, Discover and American Express.
• Personal checks are accepted with proper identification.
When your bill is unpaid, a collection agency may be chosen to manage delinquent accounts. If your account is
placed with a collection agency, you will be responsible for all costs of collection.
Cancellation Policy
• We require a 24 hour cancellation notice for a scheduled appointment.
I have rea
d and fully understand my financial responsibilities under this policy.
PATIENT/GUARANTOR SIGNATURE DATE
“Creating healthy, beautiful smiles....for a lifetime.”
Metro Dental Associates 29 Elm Street
Morristown, NJ 07960
(973) 975-0414
Fax (973)539-7558
973-538-2563
