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Dental office financial policy template

A free dental office financial policy template: payment at the visit, insurance, estimates, balances, missed appointments and payment plans.

Updated November 11, 2026

How to use it

Edit it to match how your office works, then have patients sign it at their first visit and when it changes. Keep the signed copy.

Have it reviewed for your state before you use it. State law and your network contracts limit some fees, such as charging for missed appointments or for services a plan doesn't cover.

The template

Fill in the [brackets] in your own copy. This page has no fields: nothing you'd fill in is typed here.

[Office name] financial policy
Thank you for choosing [office name]. This policy explains how we handle payment. Please ask us about anything that isn't clear.
Payment at the visit
Your estimated share is due at each visit. We accept [cash, checks, credit and debit cards, HSA and FSA cards].
Dental insurance
We file claims with your dental insurance for you, as a courtesy. Your insurance is a contract between you, your employer and the insurance company, and it decides what it pays.
Please bring your insurance card and photo ID to every visit, and tell us when your coverage changes.
If you have more than one dental plan, we file with both. Tell us about every plan you have.
Estimates
Before treatment, we estimate what your insurance should pay and what you'll owe. An estimate is not a guarantee. If your insurance pays less than estimated, you pay the difference. If it pays more, we refund or credit you.
Services your plan doesn't cover
Some services aren't covered, or are limited by how often the plan pays. We'll tell you before treatment when we know a service isn't covered, and you'll pay [our fee / the fee our network contract allows] for it.
Balances
We send a statement for any balance after your insurance pays. Balances are due within [number] days. Balances over [number] days may be [charged a fee of / sent to collections, as allowed by law].
Payment plans
For larger treatment, ask us about [payment plans / financing through (company)].
Missed appointments
Please give us at least [number] hours' notice to change an appointment. [Missed appointments may be charged $(amount), as allowed by your plan and state law.]
Minors
The parent or guardian who brings a child to the visit is responsible for payment.
I have read and agree to this financial policy.
Patient or guardian name: ________________
Signature: ________________ Date: ________

A starting point, not legal advice. Check it against your state's rules and your network contracts.

Sources

Read November 11, 2026. Where a source describes one insurer's plans, we say so.

Get the patient's share in dollars, from the benefits page

Tabruns fills in the coverage, maximum, deductible and limits from the portal for you. Tabruns reads the coverage, deductible, yearly maximum, waiting periods and frequency limits from the insurer's portal and works out what the patient owes. Patient details stay on the office computer.

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Not ready? Try the free patient portion calculator.

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