Non-Insured Patients

Payment in full is expected when services are rendered.

Insured Patients

Your insurance is a contract between you, the insured, and the insurance company. Although your insurance may assist you with partial payment of your treatment, the estimated portion, which is not covered, is due when services are rendered.

As a courtesy to our patients, we will file your primary insurance for you. If your insurance has not been paid within 60 days, you will be billed for the entire balance and payment in full will be expected at this time. We will, however, continue to work with you and your insurance company to expedite your reimbursement.

(Please Read Carefully):
We do not accept assignment of benefits for secondary insurance; however, we will provide an ADA Claim

form for you so you may file and be reimbursed by the secondary company directly.

Payment may be made by any of the following methods:
Cash Visa MasterCard Discover American Express

Information is available upon request for outside financing through the following:

Alphaeon, Care Credit and Lending Point

I understand that my insurance may pay for only a portion of the claim(s) submitted and that I am ultimately financially responsible and agree to pay for all expenses incurred for the services rendered by this office.


I request that all insurance benefits be paid directly to BlueWave Dentistry.
I authorize the release of necessary information to my insurance company to determine liability for payment and to obtain reimbursement for any claims(s).


If I am unable to keep my appointment and I do not call the dental office at least 24 hours in advance, I understand that I will be charged a broken appointment fee of $50 with the dentist and $25 for the hygienist.


If I need to reserve an appointment for over one hour, I will be asked to make a deposit of $50. Any change to this appointment must be made at least 24 hours in advance.


If this account is assigned to an attorney or collection agency, I agree to pay attorney’s fee, collection fees, court cost and interest from the date of treatment.

I understand and agree to all of the above conditions of this Financial Policy.