OFFICE POLICIES

Dear patient,
We are pleased to welcome you to our practice. We look forward to working with you in maintaining your dental health. If you have any questions, we will be glad to help you. We strive to provide you and your family with the higher quality dental care. In an effort to clarify office procedures and strengthen our relationship with you, we have outlined the following details concerning our office policies. To help us, please take the time to review and sign the office policies described below. If you have any questions concerning these policies, please feel free to ask a staff member of the doctor.

Notice of Privacy Practices

We attempt to obtain written acknowledgement of receipt of our notice of privacy practices. You may refuse to sign this acknowledgement, by crossing over this paragraph only and placing our initial next to it. In certain situations such as en emergency or when there are communications barriers, this acknowledgment cannot be obtained.

Cancellation, Broken Appointments and Office Schedule:

As a courtesy to our patients, we make every effort to confirm all appointments in advance. However, it should be noted that it is the patient’s responsibility to keep all appointments. A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointment. We request at least a 24-hour advanced notice prior to your visit, if you must change or cancel your appointment. We will assess a $98/hour for otherwise broken appointments or no-shows. This fee will increase in accordance with the amount of time you have schedules and will have to be paid before another appointment is made.

Please Note: Due to the nature of our practice, emergencies and acute walk-in patients may cause the dentist to alter their schedule. We will do our best to see each patient as close to their appointment time as possible. We appreciate your cooperation and understanding regarding these unforeseen circumstances. You receive the same careful attention. However, if time becomes a problem, please let the staff know so we can accommodate your schedule as best as possible.

X-Ray Duplication:

We are required by the state law to retain all records, including x-rays, on file in our office. They are the legal property of the office. Therefore, if you would like your x-rays, we will be glad to duplicate them for a fee of $59. We require a week notice to duplicate the x-rays.

Consent for Treatment:

The dentist has explained the nature of any condition, the nature of the procedure and the benefits to be reasonably expected compared with alternative approaches, just as there may be benefits to the procedure proposal. I understand that all procedures involve risks to some degree. These general risks may occur in connection with the procedures proposed to me: infection, bleeding, numbness, recurrence, or need for further treatment such as root canal therapy or extraction. I am aware that other unexpected risks or complications may occur and that no guarantees or promises have been made to me concerning the results of any procedure or treatment. It has also been explained that during the course of the proposed procedures, unforeseen conditions may be revealed requiring the performance of additional procedures. I have read this form and have discussed it with my dentist, and I understand it. I request the performance of procedures described. The above statement is explained to me and all my questions are answered.

Patient/guardian fully understands the discussion and explanations on the consent forms and availability of referral to a better trained specialist who regularly handles this procedure. Please Note: Plans and costs are estimates only. Dental treatment frequently changes in mid course. Additional treatments, such as root canal therapy, may be indicated if symptoms develop after treatment of decayed/injured teeth.

Authorizations:

I certify that the information provided is accurate and complete to the best of my knowledge. I hereby authorize the dentist to release any information, including the diagnosis and records of any treatment or examination rendered to me or my child, during the period of such dental care, to the third party payers and/or health practitioners. I also hereby direct my insurance carrier to make payments directly to the dental office.

Financial Policies:

Dental treatment is an excellent investment in an individual’s medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that different people have different needs in fulfilling their financial obligations, we are providing the following payment options.

INSURED PATIENTS:
We advise that our patients inquire with their insurance company regarding the dental benefit and coverage, co-payment and deductible information outlined in their policies. Patients are required to pay all deductibles and co-payment percentages, as specified in their policy, at the time services are rendered. Literally, there are thousands of insurance companies, and their payment policies can change, therefore it is impossible to give you a guaranteed quote at the time of service. We accept most dental insurances and will do our best to verify and estimate insurance coverage and your payment portion, however it is only an estimate. Therefore, any balance left unpaid by the insurance company is the patient’s responsibility.

We will file and bill your insurance as a courtesy. We cannot be responsible for actual payments made by your insurance carrier. After payments are received, you may owe more money, or have a credit which would be reimbursed to you. After 60 days, we reserve the right to request payment in full for our services from you, and let you collect the insurance fund that is due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between you/your employer and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

Also, it is your responsibility to investigate whether or not your insurance is on our network list held by your insurance company. If not, you will be financially responsible for the service fee rendered. Our office charges what is usual and customary to our area. You are responsible for payments, regardless of any insurance company’s arbitrary determination of usual and customary rates. We also will assume a $50 deductible unless otherwise indicated.

On some occasions, an insurance coverage/benefit may not be the best treatment option. After the doctor had explained all your possible treatment alternatives, nature of procedures, advantages, required appointment time and cost, you may choose a treatment which may not be covered by your insurance carrier.
Note: Please inform the office, if there are any changes in your insurance coverage.

NON-INSURED PATIENTS:
Payment is expected when services are performed, unless prior plans are made. You can benefit from a one-time new patient special offer of reduces fees, due at the first initial examination date. Please note, if you miss the cleaning appointment of this special offer, it is forfeited, and you will be charged for the next cleaning appointment.

Payment Options: (for non-insured only and not to be combined with the special discounted offers!) Payment in full: A bookkeeping courtesy of 5% is given for direct payment in full by cash, check or credit card at start of treatment, resulting in a one-time payment. (Balances over $500 only) Office payment plan: An initial payment of one half (1/2) is due at the start of treatment, with the reaming balance being due upon completion.

Financing through creditors: Many health-care creditors are offering flexible payment plans for individuals with good credit standing status. Their services are fast, confidential and can be done over the phone or the internet. Upon your approval, they usually require no initial payment, and can offer long-term low monthly payments with minimal or no finance charge. Also, pre-payments can be made anytime without penalty. Please note, a processing fee may apply to this financing. Please, inquire about our special promotional offers!

Service Charge: If I do not pay the new balance within 30 days of the billing date, a service charge will be added to the account for the current billing period. The service charge will be a periodic rate of 3% per month (or a minimum charge of $5 for a balance under $100) which is an annual percentage rate of 3% per month (or a minimum charge of $5 for a balance under $100) which is an annual percentage rate of 3% applied to the last month’s balance. In the case of default, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account of future outstanding accounts. Full payment is due and expected at the time of service, unless prior arrangements with the office have been already made. We accept cash, check and major credit cards.