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Sepi Pejham, DDS
General & Cosmetic Dentistry
Genuine care and a professional approach
Call: (408) 255-9057

Financial Policy

Payments are due the day services are rendered. We accept CASH, CHECKS, VISA, AND MASTER CARD. If you have insurance or discount plan coverage (HMO), then all PATIENT’S PORTIONS and/or CO-PAYMENTS are due on the day of service. Please note that WE CAN ONLY ESTIMATE WHAT YOUR INSURANCE POLICY MAY PAY. This is because each insurance plan has its own specific limitations and exclusions. There is no guarantee that they will actually make any payments for you until a claim has been submitted to them.

For patients covered by an insurance we will, as a courtesy, send a claim to their insurance company. However, in order to provide the service to you, we must have your complete insurance information and confirmation of your coverage. It is your responsibility to provide us with up to date insurance information. If this information is not provided to us in a timely manner we will not be able to bill your insurance company and you will be responsible to make full payment on the date of service. You are ultimately responsible for all charges regardless of your benefit coverage.

If we do not receive payment from your insurance company within 45 days of billing them, the entire balance becomes your responsibility. The insurance agreement is between you and your insurance company and you will be expected to contact them directly should a problem arise.

TO ALL ACCOUNTS WITH A BALANCE DUE OF OVER 45 DAYS, A FINANCE CHARGE OF 1.5% PER MONTH (18% annual) WILL BE ADDED.

We may begin a more aggressive collection measure for accounts with balance of more than 90 days past due.

A 24-hour notice is required for all cancellations without exception. Your appointments are especially reserved for you. There will be a $25 cancellation fee for the first untimely cancellation. From then on $50 charge for Hygiene and $150 per hour charge for doctor’s time for any missed appointments without a proper notification. Such charges will be applied without notice upon occurrence of the missed appointment. A workweek is from Monday through Thursday except for holidays. Please note that VOICEMAIL DOES NOT CONSTITUTE APPROPRIATE CANCELLATION NOTICE. Monday cancellations are only accepted before noon on the previous Thursday.

Should this account become past due, the patient agrees to pay any reasonable additional fees, including any and all collection agency charges, and/or legal fees necessary for collection of this account.