Tooth Fairy Pediatric Dental Clinic Financial Policy

TOOTH FAIRY PEDIATRIC DENTAL CLINICFINANCIAL POLICY

Welcome to our practice! Thank you for choosing the Tooth Fairy Pediatric Dental Clinic for such an important concern as your child’s dental healthcare needs.

Our first priority is to provide your child with the highest in quality dental care. In order to consistently do so, we must request that full payment and/or estimated co-payment be paid at the time services are rendered. For more extensive dental treatments including, but not limited to, out-patient surgery and in-office sedations, financial arrangements must be in place a minimum of two weeks in advance of the treatment date, or the appointment will need to be rescheduled or canceled.

For your convenience, we offer a wide variety of payment options.

Cash/Money Orders
Checks
VISA, MasterCard, Discover
CareCredit

The parent or guardian accompanying the child is responsible for payment and/or co-payment at the time of service. If a guardian is accompanying the child, for example a grand parent, the guardian is responsible for payment. If you are not prepared to pay on the day of service, the appointment will need to be rescheduled or canceled.

Dental Insurance/Medicaid/Kids Connection As a courtesy toyou, we will prepare and submit the necessary forms and/or reports to obtain benefits from your insurance company. In order to submit your dental claims you must supply your current dental insurance information to our office. Informationneeded for insurance will be: the policy holders name, social security number and date of birth. As well as the Plan Name, Group Number and Insurance Company, including mailing address. In the absence of this information, payment in full will be required on the day of service. For Medicaid/Kids Connection we will need you to supply a copy of the current ID card so we have the ID number. If you choose to have procedures performed that are not covered by Medicaid/Kids Connection,payment in full will be required on the day the service is rendered.

If your dental insurance company requests additional information from you, such as a Coordination of Benefits Statement, and is withholding payment to our office until such information is received from you; our office reserves the right to delete your dental claims from our system, and require payment in full. We will allow two weeks for you to provide this information to your insurance provider before taking action to delete the claims and require payment in full.

If you have non-assignable insurance (meaning your insurance company will not mail your benefit check directly to our office) our office will submit your insurance claims for you, however; payment in full will be required on the day of service.

If you have non-assignable insurance as your primary coverage with secondary coverage through Medicaid/Kids Connection you must, within 10 business days of receiving your insurance reimbursement check Endorse the check and mail it to our office, along with the Explanation of Benefits (or a copy of the EOB) that will accompany the check. Our office must receive your insurance payment and a copy of the Explanation of Benefits before we can forward your claim to the Nebraska Health and Human Services Medicaid Office.

Failure to follow this 10 day procedure will result in your account and associated patients to be dismissed from the Tooth Fairy Dental Clinic, your account will be turned over to our collection agency, you will be personally responsible for all unpaid fees and we will notify Nebraska Health and Human Services of yournon–compliance, which may result in you losing your Medicaid coverage.

Missed Appointments: Pleaserealize we have reserved valuable time foryour child. If for any reason you must cancel your child’s appointment, you must call our office andnotify us of the cancellation, preferably with a minimum 24 hour notice. Multiple missed appointments, without notification, will result in dismissal from the Tooth Fairy Dental Clinic.

All personal payments received by the Tooth Fairy Dental Clinic will be applied first to any, and all, monthly billing charges and /or finance charges before being applied to the patient’s principal balance.

All account balances unpaid over 30 days will be accessed a monthly finance charge on the outstanding balance.

If you becomelate or default on your account all patients associated with your account will be dismissed from the Tooth Fairy Dental Clinic and we will seek professional collection resources to help collect the balance due. Also, any and all attorneys’fees and other costs for collection will be added to the existing account.

A $25 fee will be assessed to your account for any checks returned for insufficient funds.

I have read, understand, and will abide by the Financial Policy of the Tooth Fairy Pediatric Dental Clinic.

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Signature of Parent of GuardianDate