Please bring all your insurance details to your appointment (usually a wallet card). Reception will setup so we can electronically submit your claims to ensure prompt repayment to you.
Dental plans in the marketplace today are too numerous and varied to allow us to know the details of all of them. Your particular dental plan may or may not cover the full extent the costs you incur for your dental treatment. This can occur because the fees in our office are based on factors which may not have been considered by your insurance carrier. Furthermore, there may be certain procedures performed which are not covered through your dental plan. These factors are beyond our control.
PLEASE REVIEW YOUR DENTAL PLAN CAREFULLY TO ENSURE YOU UNDERSTAND THE EXCLUSIONS AND LIMITATIONS OF YOUR PLAN.
Payment for dental services is expected when treatment is rendered. You will be informed of your amount at the time treatment is completed and payment is requested immediately after treatment. Any insurance will be submitted at the same time and you should receive payment shortly.
In the event of an outstanding balance a 2% service charge will be applied to all account balances outstanding for more than 30 days.
By signing you are acknowledging:
I am financially responsible for any balances due and authorize the dentists to release any information for any claim.
I certify that I have read or had read to me the contents of this Payment Policy, filled the Patient Information completely and accurately to the best of my knowledge and do realize the risks and limitations involved.
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required bylaw.
We collect information from our patients such as names, home addresses, home and/or work telephone numbers, and email addresses.
Contact information is collected and used for the following purposes: To open and update patient files, to invoice patients and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process credit card payments, or to collect unpaid accounts, to process claims for payment or reimbursement from third‐party benefit providers, insurance companies and agencies, government agencies, to send reminders to patients concerning the need for further dental examination or treatment, and to send patients informational material about our dental practice.
Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of dental services from whoever has been written as financially responsible for the account.
We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed: To all third‐party benefit providers, insurance companies and government agencies where a claim is being submitted for reimbursement or payment of all or part of the cost of dental treatment. To other dentists and dental specialists, where further information and/or discussion is required. To other dentists and dental specialists if the patient has been referred by us to the other dentist of dental specialist for treatment. To other health care professionals such as physicians if the patient has been referred by us to the other health care professional for either a second opinion or treatment. Where we are seeking and/or providing information to the following: laboratories, radiology centres, hospitals, etc. To include the following when necessary, such as: videos, pictures, slides, etc., for educational purposes.
If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure the prospective purchaser safeguards all personal information.
Dentists are regulated by the Royal College of Dental Surgeons of Ontario which may inspect our records and interview our staff as part of its regulatory activities in the public interests.
I consent to the collection, use and disclosure of my personal information as set out above.