Information on Office Policy and Financial Responsibility
Welcome to our Practice:We appreciate the trust you have shown in selecting us to provide for your child’s dental needs. Treatments of children’s dental problems, often requires the care of a Pediatric Dentist, who has an additional two years of specialty education, in the treatment of children’s health concerns.
Our intent is to make you feel comfortable in our office. Every effort will be made to ensure successful treatment of your child. Our office is designed and equipped to maximize safety, comfort and efficiency, and our staff is highly skilled in their respective areas of health care delivery. We believe that a mutual understanding of our office policy provides the atmosphere in which optimal health care can be delivered.
Insurance:knowing your insurance coverage is your responsibility.
Please familiarize yourself with your policy’s restrictions and guidelines. If you have dental insurance, we will make all attempts to help you receive your maximum allowable benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policy, and your child’s coverage at the time of service.
Your estimated portion is due at the time services are rendered.
We accept cash, Check, Master Card, Visa for your convenience. We will be happy to process your insurance claim form for you. Please note that what we collect is an estimate: therefore, a balance still may result after insurance pays. Any overpayments will be reimbursed after insurance completes payments.
All (NSF) returned checks are subject to a reprocessing fee of $25.00.
Account balances older than 60 days will accrue interest charges of one percent per month and may be subject to additional collection fees.
We will gladly discuss your proposed treatment and answer any questions relating to your insurance.
You must realize, however, that:
- Your insurance is a contract between you, your employer, and the insurance company.
We are not a party to that contract.
- There are a large variety of insurance programs available today. These programs vary in their “Deductible” and “Pre-authorization” requirements, covered benefits, and the extent of benefits, which range in percentage of total costs. In most cases, insurance companies do not cover the stated percentage of cost due to “UCR” or fee of schedules. UCR is defined as usual and customary, and reasonable fees by the insurance company’s standards. Fee schedules are planned reimbursement by insurance companies for services and have no relationship to submitted fees.
- Not all services are covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While the filing of dental insurance claims is a courtesy that we extend to our patients,
all charges are your responsibility from the date services are rendered. We realize that temporary financial problems may effect timely payment of your account. If such a problem does arise, we encourage you to contact us promptly for assistance in the management of your account.
If you have any questions about the above information or any uncertainty regarding insurance coverage,
Please don’t hesitate to ask us. We are here to help you,
For those patientswithout dental insurance, full payment is required at the time of treatment.
Past Due Accounts: Occasionally, due to commitments that cannot be kept or insurance policies that have been misunderstood, accounts fall into arrears. We assign accounts that are in arrears to a
Collection- service. This can be avoided by keeping in contact with us; we do not want this action anymore that you do.
Hospital Patients: Hospital patients are billed separately for the day surgery and any anesthetic procedures by the hospital or anesthesiology medical group. Prior to hospital or in office anesthesia
Dental treatment, we collect the percentage of our fees your insurance does not cover.
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Additional Services: After hour visits, written reports, professional consultations outside the office, sedation, and patients who require “Special Behavior Management” (more time and personal), may be charged an additional fee, and will be billed based on time and complexity.
Records: We keep a record of the health care services we provide you. You may ask to see any copy of that record. You may also ask us to make corrections, if applicable, to that record. We will not disclose your child’s record to others unless you directly ask us todo so, or unless the law authorizes or compels us to do so.
Treatment: When your child is brought in for an initial exam, a comprehensive treatment plan will be presented to you by the doctor and staff for your consent. Please ask any pertinent questions regarding the treatment plan. If treatment is changed during an appointment, generally, this is because of the doctor’s clinical evaluation of the dental condition at the time of treatment, not during the initial exam. You will be informed of any treatment changes and charges. If at any time you need clarification regarding your child’s treatment please contact us.
Recall Exams: During recall exams all necessary treatment will be presented to you for your consent.
Emergency Exams: The doctor will primarily focus on treating your child’s emergent needs and will inform you of any necessary treatment and obtain your consent and allow you the opportunity to clarify any treatment issues.
Please sign below to indicate that you have read and understand our office policy. We will be happy to answer any questions you may have.
Child / Children’s name(s)
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______Date:______/______/______
Signature Parent or Guardian Print name