HAS ANY MEMBER OF YOUR FAMILY BEEN A PATIENT IN THIS OFFICE BEFORE? YES

To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.

Thank you again for choosing our office to serve your child's dental needs and allowing us to be part of your family's prevention program against dental disease. Parents frequently have questions regarding the scheduling, duration and frequency of pediatric dental visits. For this reason, you may want to keep the following general information for future reference.

Because our mission is to prevent dental disease through timely treatment and patient education, we want to accommodate everyone's schedule. Understandably, many parents prefer that their children do not miss school for their dental visits. However, since most of our patients attend school, it is impossible to schedule all appointments during the after school hours. In order to accommodate as many families as possible, we reserve after school time for shorter appointments such as cleanings and exams. Longer appointments and appointments requiring the use of nitrous oxide, or laughing gas, will be scheduled during school hours. If an emergency arises, we will do our best to schedule you on that day.

When you make an appointment, please be certain that your schedule allows you to come on time. We understand that last minute changes occur in people's schedule. Nevertheless, consistency with your child's dental appointments is a key factor in maintaining good oral health. Your child is important to us and we want your family to be motivated to help us prevent dental disease. In order for us to maintain our high standard of care, 48 hours notice is required if you are unable to keep your appointment time. A fee of $50 will be charged to your account for a cleaning appointment and $75 for operative appointment cancelled within 48 hours or failed appointments. In the case that there are 3 or more failed appointments or last minute cancellations, we reserve the right to terminate our relationship as your dental care provider.

Please be aware that Dr. Gorgani and Dr. Amarnath are not in network providers for any insurance companies. We recommend that each family know their dental plan, including maximums, deductibles and percentages prior to their appointment.

For children requiring treatment visits, an estimate will be made for the cost of the total treatment. At the time of the first treatment visit, any portion the insurance does not cover will be due. For families without dental insurance, full payment for treatment rendered that day will be due. The parent who brings the child to their appointment is the responsible party, independent of what a divorce decree may state. Reimbursement must be made between the divorced parties. We will not intervene.

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount that insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 90 days a finance charge of 1.5% will be added to your account each month until paid. We will be glad to send a refund to you once insurance has paid us.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment; we at no time guarantee what your insurance will or will not do with each claim. Please make sure we have your correct insurance information.

Fact 1–FEW INSURANCES PAY 100% OF ALL PROCEDURES

Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90-100% of all dental fees. Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.

Fact 2 –BENEFITS ARE NOT DETERMINED BY OUR OFFICE

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee exceeded the usual, customary, or reasonable fee (“UCR”) used by the company. A statement such as this gives the impression that a fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate. Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily choose a level they call the “allowable” UCR Fee. Frequently this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit. Unfortunately, insurance companies imply that your dentist is “overcharging” rather than saying that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.

Fact 3 –DEDUCTIBLES & COPAYMENTS MUST BE CONSIDERED

When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as it’s usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00, leaving a remaining portion of $70.00 (to be paid by the patient Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.

MOST IMPORTANLY, keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment. We will be unaware of any of these changes unless you bring them to our attention.

In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. If you have any questions, please feel free to ask our front desk staff. We are dedicated to providing the best possible care and service to your child and regard your complete understanding of our financial policies as an essential element of care and treatment. A treatment plan will be prepared for you, which will detail your child’s dental needs as well as the related estimated costs of that treatment. Our office is a fee for service dental office, and full payment or insurance co-payments are due at the time of service.

• Payment is due at the time of service unless other arrangements have been made in advance by either yourself or your dental plan coverage. For your convenience, we will accept cash, check, Visa or MasterCard.

• Your insurance is a contact between you and your insurance company. As a courtesy, upon verification of coverage, we will file your insurance claim for you, collecting at the time of service and estimated co-payment, if you assign the benefits to the doctor; in other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will look to you for payment. If we later receive a check from your insurer, we will refund any overpayment.

• All dental plans are not the same and do not cover the same services. In the event your dental plan determines a service to be “not covered” or over what they deem “usual and customary charges”, you will be responsible for this amount. Payment is due upon receipt of statement from our office.

• We will look to the guardian of the minor for consent and financials regarding any and all services rendered.

Your understanding and observation of these policies is greatly appreciated. Please keep in mind, we are trying to be on time and fair to all families so that we can provide our best to you.

By signing below, I acknowledge that:

• I have received and read a copy of the above information.

• I understand that I am financially responsible for any charges not covered by my insurance benefits for my family’s account.

• I may request a copy of the above policies at any time and that Cupertino Pediatric Dentistry reserves the right to change any of the above policies at any time.
• I will be offered a copy of the following information at my child’s appointment:
•  
  • Notice of Privacy Practices

  • Dental Materials Information Sheet

  I acknowledge by signing this form, I will be financially responsible for my child’s account.

  • I hereby authorize DR. MAHNAZ GORGANI, DR. AMARNATH and/or their associates to perform any and all treatment for my above named child and consent to such methods, drugs, and agents as may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled