REQUEST FOR PAYMENT DEFERRAL DUE TO COVID-19
Please read below and then answer ALL fields at the bottom and click submit. The form will not be sent to us until ALL fields are entered and you click SUBMIT and see an acknowledgment that the form was submitted. You will also receive a copy of the request to your email. If you do not receive an email copy within one hour, please re-submit the form.
We understand the cost of orthodontic treatment is challenging for many to pay in full at the beginning of treatment which is why our office has always been proud to offer interest free in house financing to all of our patients to help make orthodontic treatment accessible to all. As you are aware, your monthly payment has never been related to having an appointment in that month and many of our patients are seen every 4-6 months but still pay monthly to help finance treatment. We do understand, however, that these are exceptional times for many financially and that others may simply wish to put their payment plans on hold during our office closure until they know when we will reopen. We are, therefore, offering those who need financial relief or wish to put a “hold” on their contract throughout the duration of our closure to do so by visiting our website and completing this form below.
If you choose to defer your payment please read the following carefully:
1. The form MUST be completed and received by May 5th, 2020 to put your May payment on hold. Any forms received after that date will not be processed until the June payment and your May payment will still be processed.
2. Your total balance will remain unchanged and any deferred payments will be added to the end of your contact (i.e. your contract will be extended by "x" number of months.)
3. You may wish to check with your insurance company before changing your payment plan if this will in any way affect your ability to be reimbursed for your orthodontic claim.
4. Payments will resume in the month that our office reopens for all payments put on HOLD even though it may take us some time to get everyone back in for their next appointment. (If you have extenuating circumstances requiring additional financial relief beyond that time please reach out to our office directly to speak to one of our financial coordinators)
