King Street Dental Centre Terms and Conditions
INSURANCE: You are responsible to know your plan coverage, exclusions, limitations furthermore you would be aware of non-covered benefits such as missing teeth, specific exams, prophylaxis, fluoride, x-rays etc. The estimated amount not covered by your insurance is due at the time of treatment. We accept VISA, DEBIT, CASH or MASTERCARD. To help you accept an extensive treatment plan, we are offering financing on extensive treatment. All estimates are subject to final approval by your dental insurance plan, therefore the amount due is subject to change after final explanation of benefits have been paid.
INITIAL PAYMENT FOR DENTAL TREATMENT: Most plans are covered for routine clinical exam and cleaning and no deductible is due for diagnostic or preventative treatment unless otherwise stated. Deductible for basic and or major services customarily include fillings, crowns, extractions, root canal therapy and periodontal treatment. Deductibles are usually $50-$100 per individual or $200.00 per family annually. Some dental plans my have a co-insurance payment usually between 10%-20% for all basic services. If your plan requires you to pay either it is due upon treatment completion.
RESIN-BASED COMPOSITE RESTORATION (fillings): Most dental insurance plans do not allow full benefits for composite (white fillings) performed on posterior teeth (back molars). The plan benefit will customarily pay for less expensive treatment, such as Amalgam (silver/mercury-based restoration). For the best of our patients, we recommended and we ONLY place composite based (white) fillings. The difference is usually $50-70 per filling and the patient is responsible for the difference in cost.
MISSED APPOINTMENT/ CANCELLATIONS: Please note that we require a minimum of 48 hours notice to change or cancel an appointment. The fee for short notice cancellation or missed appointments will result in a $100.00 charge to your account. This payment must be taken care of in order to reschedule an appointment at our clinic in the future.
TRANSFERRING RECORDS: You will need to request in writing if you would like us to mail, fax, email etc. your dental records with Dr. Reddy. We need at least 8 hours in advance to prepare your record to be transferred
PAST DUE ACCOUNTS: If your account is turned over to a collection agency or attorney, you agree to pay all fees including and not limited to attorney fees, court fees and collection agency fees.
This is an agreement between Dr Reddy, as a provider of professional services and creditor with the patient, debtor named on this form. By Reading and signing this agreement, you are agreeing and accepting the policy in full.
COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION: Our office understands the importance of protecting your personal information. This office will collect, use, and disclose information about you for the following purposes:
- · To enable us to contact you (your child) and to book and confirm appointments
- · To advise you of treatment options
- · To communicate with other health care providers, including medical and dental specialist, and general practitioners
- · To comply with legal and regulatory requirements, including the delivery of patients and charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required. According to the provisions of the Regulatory Health professions Act
- · To comply with agreement/undertakings entered voluntarily by Dr A Reddy with the Royal College of Dental Surgeons of Ontario, including the delivery/ or review of patients charts and records to college in a timely fashion for the regulatory and monitoring purposes
- · To prepare material for the Health Professionals Appeal and Review Board
- · To process credit card payments
- · To collect unpaid accounts
We also use this information to provide you with excellent treatment. We may disclose patient Health information (PHI) to third parties that perform services for King Street Dental Centre in the administration of your benefits in accordance with HIPAA and/ or PIPEDA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for King Street Dental Centre in the administration of your benefits. Our affiliated do not sell, share or rent our users personal identifiable information unless required by law, do not send any emails or other communications without users’ permission.
By signing below, you authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. You have been advised of the privacy policy of the office and that the personal information will be collected, used, and disclosed with the guidelines of the policy. You authorize release, to your insurance company/ plan administrator, the information contained in the claims electronically and for direct assignment to the dental office if applicable. You understand that responsibility for payment of dental services for yourself and your dependents is your responsibility for fees associated with these services.
By signing below, you agree that you have reviewed the above terms and conditions set out by King Street Dental Centre. You agree that Dr A Reddy and staff can collect, use, and disclose personal information as set out in the above terms and conditions.
By signing below, you agree that you are given an accurate and complete personal, medical, and dental history form and have not omitted any information.