Welcome to the office of Dr. Megan E. Stowers DDS, MS, PLC Specialist in Pediatric Dentisry! To avoid any misunderstandings, we would like to inform you of some of our policies. Please read the information carefully and sign below.
Ultimately, you are responsible for your account. As a courtesy to our patients, we will file your insurance claim. An insurance policy is a contract between insurance carrier and employer. They determine the benefits you receive. We will estimate your co-pay and ask you to pay the co-pay at the time of service. If there is any amount your insurance does not cover, or if the claim is denied, you will be responsible for that amount. We urge you to be fully informed of the insurance benefits available to you.
Payment is due at the time services are rendered. For your convenience, we accept cash, checks, credit cards and Care Credit. There will be a $10.00 monthly rebill fee on any unpaid balances after the first statement. If your account becomes delinquent beyond 30 days, you may be responsible for all costs incurred to collect on the account including collection agency fees, court costs, and attorney’s fees as well as interest accrued. Please let us know if there are extenuating circumstances and we will be happy to make special payment arrangements. We realize that many families are in a state of change. Divorce, separated, single parent and blended families are now common. The policy in our office is the parent who requests treatment for the child is responsible for all fees incurred.
If it is necessary for you to reschedule or cancel your appointment, we request at least 24-hour notice. This allows us the opportunity to offer this time to others. Thank You!
Patient Acknowledgement and Consent Form:
The Health Insurance Portability and Accountability Act of 1996 (”HIPAA”) provides safeguards to protect your privacy; which was implemented on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office and copies are available for your convenience. What this is all about: Specifically, there are rules and restrictions on who my see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the US Department of Health and Human Services. I hereby authorize the professional office named above, its director, administrative staff and clinical staff or assignees, medical information services and billing departments to release any and all medical and dental records and information from my date of birth to the present, unless specified otherwise, relating my care and treatment (including x-rays, photographs, electronic and digital files, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services). I understand this consent shall remain in force from this time forward.
Patient Acknowledgement and Consent
I have read and understood this form. I am signing it voluntarily. I authorize and consent the disclosure of my health information and/or my minor children's treatment as described in this form and/or the notice of privacy practices.