Dental Financial Responsibility

We are committed to providing you and your family the best possible care, and are pleased to discuss our professional fees with you at any time.  Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or responsibility.

PHS is not a free clinic. Patients without insurance are eligible to apply for a health care discount based on current Federal Poverty Guidelines. Health care discounts are offered on a sliding fee scale. The sliding fee scale takes into account family size and income determined on the Federal Poverty Guidelines. Nominal fees charged for essential services will be collected. Proof of household income (POI) is required to receive the sliding fee.

Payment in full is due at the time of service. In the case of a minor, the patient’s accompanying adult, parent, or guardian is responsible for payment at the time of service.


We accept most insurance plans. Patients are responsible to check with their insurance company on any restrictions.

All insurance co-pays are due at the time of service.

We will submit insurance claims on your behalf; however, we will not become involved in in disputes between you and your insurance company regarding deductibles, co-insurance, covered charges, secondary insurance, etc., other than to support factual information necessary. You are responsible for the payment of your account.

We accept cash, checks, Visa, MasterCard and debit cards.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This
    includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit or call 312-353-5160