Financial Policies

Thank you for choosing our team of dental professionals to service your dental needs. We are committed to providing you with the highest quality care. We appreciate the confidence you have placed in us and will do everything possible to continue to warrant your confidence as we serve you. In order to continue providing outstanding care to all of our patients, we ask that you please understand and agree to the following office financial policy.


Dental insurance is designed to help offset the cost of dental care. Insurance estimates provide a table of allowances that will assist you in determining your approximate out of pocket expenses.

  • On your behalf, we will contact your insurance company to help determine your level of benefits. Please note that insurance estimated and pre-estimates are not a guarantee of benefits. Not all services are a covered benefit with the contracted insurance.
  • Your insurance policy is a contract between you and your insurance company. Our office can not accept responsibility for negotiating a settlement with your insurance company on a disputed claim.
  • Filing insurance claims is a courtesy that we will gladly perform for you to help you maximize your benefits. However, you are responsible for any amount not covered by your insurance, for whatever the reason.
  • We generally accept assignment of benefits (payment) from your insurance company. But we can reserve the right to refuse assignment as we deem necessary. In that case, full payment is due at the time of service and your insurance company will reimburse you directly.

Payment Policy:

As a condition of your treatment by this office, financial arrangements must be made in advance. We depend upon payment from our patients for the costs incurred in their care and the financial responsibility on the part of each patient must be determined before the treatment. We will discuss financial options with you before rendering treatment.

By signing below, you are agreeing to all of the terms contained in this financial policy, including the following:

  • Payment is due in full at time of service unless prior written financial arrangements have been made.
  • We reserve the right to charge a missed appointment fee for no-shows or cancellations with less than 24 hours’ notice. Cancellation fee can range from $25-$50.
  • We offer a courtesy adjustment to patients who pay for their treatment in full prior to their initial treatment.
  • I understand and agree that any account balance not paid within 90 days will be subject to collection activity. I understand that Sunrise Family Smiles, PA may retain the services of an attorney to assist with the collection of outstanding balances.
  • I understand and agree that I will owe an attorney’s fee of an additional 33 1⁄2% of the amount I owe to Sunrise Family Smiles, PA, plus 1 1⁄2 % per month (18% per annum) on the unpaid balance owed, plus court costs on any account not paid within 90 days of the last date of service.
  • I understand and agree that, ultimately, I am responsible for payment on my account. As guarantor, I am responsible for any outstanding balances for other family members listed on the same account, due to Sunrise Family Smiles.

Payment Options:

Sunrise Family Smiles, PA has the following payment methods to choose from:

  • Cash, Check or Money Order
  • Visa, Mastercard, Discover and American Express
  • We also offer convenient monthly payment options from CareCredit Healthcare Financing Company and Lending Club. They allow you to pay over time and no annual feels or pre-payment penalties.

By signing below, I understand and agree with the financial policies of Sunrise Family Smiles, PA.


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.