Dental Insurance Claim Processing Policy

Dental Insurance Claim Processing Policy

Because dental insurance companies have become increasingly difficult to work, we have been forced to establish a policy which does not place us in a constant confrontational role. It is your dentist's responsibility to recommend what you need. All recommendations are based on Diagnostic (x-rays) and clinical picture and presented to you by your dentist or by the office manager. Your dentist will give you options (if any) for the treatment recommended, will answer all questions you might have about it and will help you decide what treatment would be best for you. When your office visit is completed you will be asked to pay an ESTIMATED amount for the service provided. Our estimate is based on the information provided by an insurance representative. The insurance given to us is not a guarantee of payment or approval for the treatment recommended by your dentist. We will send a dental claim on your behalf and we will answer any questions your insurance company may raise about diagnosis or treatment in an appropriate, timely manner. It is important you understand we are not part of the relations between you and your insurance. If insurance denies benefits for patients’ treatment for any reason, the patient is financially responsible for all charges andfor outstanding balances on account. We are unable to "force" an insurancecompany to fulfill its obligations to you. If the insurance company does not payyour treatment in a reasonable period of time (more than 2 months), patient is responsible to pay the balance. All credits, if any, will be returned to the patientupon receiving finial payment upon receiving finial payment from the insurancecompany.We would love for you to be happy and help you to accept the recommended treatmentby providing assistance with your benefits. There is a way to help, but it does notinclude taking on total responsibility for the decisions of your insurance company.

I HAVE READ AND UNDERSTAND THE INFORMATION ABOVE. IACKNOWLEDGE THAT I AM RESPONSIBLE FOR ALL CHARGES INCURREDFROM SERVICES RENDERED BY All Kids Dental, LLC

Financial Policy

Our fees are based on the time, experience and the quality of the products and materials we use in performing your treatment.

Insurance

As a courtesy to all patients we will verify your dental insurance benefits, but youare responsible to know your plan coverage, exclusions and limitations. Furthermore, you should be aware of non-coverage benefits such as a missingtooth clause, crown/bridge/denture restorations, bruxism, downgraded limitationsfor fillings and porcelain on crowns on molars, frequency limits for exams,prophylaxis, fluoride and x-rays, etc. Insurance benefits are determined by your employer, not your dentist.The estimated amount not covered by your insurance is due at the time of treatment and may be paid by cash, personal check, Visa, MasterCard, America Express or Discover. To help you accept an extensive treatment plan, we areoffering a CareCredit dental treatment Financing Program. This service offers 12months’ interest free financing. All estimates are subject to final approval by yourdental benefit plan; therefore, the amount due is subject to change after finalexplanation of benefits have been paid. (Initial)______

Initial Payment For Dental Treatment

Most plans are cover for a routine clinical exam and cleaning. No deductible is due for diagnostic or preventative treatment unless otherwise stated. There aresome plans with coinsurance payment for x-rays and dental exam. Deductiblesfor basic/major services customarily include fillings, crowns, extractions, rootcanal therapy, and periodontal treatment. Deductibles are usually ($25-$100 per individual up to $225 per family annually) a— 20% co-payment for all basic services (most cases)

Resin-Based Composite Restorations

(Fillings): Most dental benefit plans do not allow full benefits for composites (whitefillings) performed on posterior teeth (back molars). The plan benefit willcustomarily pay for less expensive treatment- AMALGAM (silver/mercury basedrestoration). We recommend and we place only composite-based (“white”) fillings.The difference is usually $15-$35 per filling and the patient is responsible for thedifference in cost. Please ask our front desk or doctor if you need moreinformation about composite-based “white” fillings. (Initial)______

Pulp-Cap Treatment

(medicament to protect nerve chamber): Most dental plans do not allow additionalbenefits for pulp-cap treatment (this procedure is utilized when the filling is verydeep). The nearly exposed nerve is covered with a protective medication to helpwith healing and repair via formation of secondary dentin. The cost of thistreatment is $40- $80 per tooth (depends on your insurance coverage) and the patient is responsible for payment at the time of treatment. If your insurance doesnot cover it or does not allow separate benefits, you will be charged a contractedfee (between us as a provider and the insurance) (Initial)_____

Financial Charges

All returned checks are subject to a $25 fee. We have the option to report yourbalance with us to any credit reporting agency and credit bureau. (Initial)______

Past Due Accounts

In the event that your account is turned over to a collection agency or attorney,you agree to pay all fees including and not limited to attorney fees, court costs,and collection agency fees. (Initial)_____

Missed Appointment Fee

Please note that there is a broken appointment fee of $50.00 for all appointmentsnot given at least 48 business hours’ notice. All Kids reserves your appointmenttime exclusively for you. He does not “double Book” appointments. Please beconsiderate and give us a call in advance if you need to reschedule or cancelyour appointment. (Initial) _____

This is an agreement between All Kids Dental, LLC, asa provider of professional services and creditor, and the patient/debtor named onthis form. By reading and signing this agreement, you are agreeing and acceptingthis policy in full. I HAVE READ AND UNDERSTAND THE ABOVEINFORMATION; ALL MY QUESTIONS WERE ANSWERED TO MYSATISFACTION; I UNDERSTAND AND AGREE TO ALL POLICIES OF ALLKIDS DENTAL, LLC

Date: ______

Signature: ______

Patient’s Name: ______

ACKNOWLEDGEMENT OF RECEIPT

NOTICE OF PRIVACY PRACTICES

Patient Name: ______Date of Birth: ____/_____/______

By signing this form, you acknowledge that we have provided you with our Notice of Privacy. It informed you on how we can use and disclose your health information. It also describes certain rights you have about your health information kept by us.

Authorization of PHI Disclosure

I authorize Personal Health Information to be disclosed to the following recipients:

Name of Person #1: ______Relationship to you: ______

Name of Person #2: ______Relationship to you: ______

______

Signature of Patient, Parent or Authorized Representative Date

______

Print Name of Patient, Parent or Authorized Representative

For office use only
To be completed only if Acknowledgement is not signed.
1. Was the patient given a copy of the Notice of Privacy Practices? [ ] YES [ ] NO
2. Please explain why the patient was unable to sign this Acknowledgement and our efforts to
try to obtain the patient’s signature:
______
______
Name / Title Date

CERTIFICATION AND CONSENT FOR TREATMENT

I certify that I am the patient or parent/legal guardian of the patient listed above and the information provided in this form is true and correct to the best of my knowledge. I also give my consent for my child or myself to receive a complete oral and dental examination (including any necessary x-rays) and dental cleaning. After consultation, I consent to all forms of treatment, medication, and therapy indicated for the dental care of the above named patient. This consent shall remain in full force and in effect until cancelled by either party. I also understand that I am personally responsible for any patient portions left on my account. This agreement is made with All Kids Dental, LLC

Date: ______

Signature: ______

Patient Name: ______

Informed Consent for Photographs

Patient Name: ______Insurance ID# ______

Parent/Guardian Name: ______Date of Appointment: ______

Patient Photographs:

Photographs will be taken when deemed necessary by the doctor for the purpose of documentation, planning treatment procedures, referrals for specialty care, or for filing insurance claims.

Permission/Denial to use photographs (initial next to your selection):

______I hereby grant permission to take photographs for the purpose of documentation, planning treatment procedures, referrals for specialty care, or for filing insurance claims. The photographs will be maintained as part of the patient record. By signing this form, you will consent to our use and disclosure of protected health information to carry out treatment, payment activities, and healthcare operations.

______I do not grant permission for taking photographs for the purpose of documentation, planning treatment procedures, referrals for specialty care, or for filing insurance claims.

I have read and understand the “Informed Consent for Photographs”:

Signed:______

Relationship to Patient:______Date: ______

Office Phone and Other Electronic Device Policy

We encourage you to enjoy the use of your phone or other electronic device, with some limits, in our dental office. In order to protect the privacy of the patients, parents and staff, we do ask that you limit some uses and we help you understand those limits below.

You are free to quietly use your phone and other electronic devices in our lobby:

 You may take pictures of your children (especially for their first dental visit) at the designated picture area in our lobby.

 Please read, text, play games, and other quiet activities on your phone. Please turn off any audio, or use earphones. Any conversations should be quiet and discreet. Any content should be appropriate for children who could see or hear your device or conversation.

To respect the privacy and remain courteous to our patients receiving treatment, device use is limited in any treatment area:

 At all times: no pictures, video or audio recording may be taken to protect the privacy of other patients receiving treatment, patients, and staff.

 Before treatment begins: you are welcome to use your phone for quiet activities, such as games, social media and texting.

 Once treatment begins: please do not use any electronic device, all people should be completely focused on supporting patient care during treatment.

o If an urgent call or activity occurs, please excuse yourself to the lobby area.

If an urgent call or activity occurs, please excuse yourself to the lobby area. I have read, understand and agree to this policy. I understand that any pictures, audio or video recording outside of those authorized above, created in the dental office, will be the exclusive property of the dental office, and I may not use, display or distribute those files in any way.

Patient Name: ______Date:______

Patient/Parent/Guardian Signature:______