Dear Parents,
We appreciate your selection of this office to serve your dental needs. Our goal is to provide the best possible dental care for our patients. We want your children to enjoy optimal dental health throughout their life. This statement has been prepared to give you some information about our office policies. Please ask the front desk staff if you have any questions about the areas covered in this statement.
ESTIMATES
Before we begin treatment, we will perform a complete diagnosis. Based on that, we will give you an estimate of the total charges for your treatment. As we proceed with your treatment, we may encounter additional problems, which may not be apparent to us at the time of the initial examination. In this event, we will fully discuss the problem, including the effects, if any, on your financial arrangements. We will not proceed without your approval.
APPOINTMENTS
If you are unable to keep a scheduled appointment, we ask you give us at least 24 hours notice. Failure to give us appropriate notice will result in a charge of at least $25.00. The charge will depend on the length of your appointment. Failed appointment charges are not covered by insurance.
INSURANCE
As a courtesy to you, we will bill your insurance company for services rendered. If we are to provide this service you must supply us with a copy of your insurance card and complete information regarding your insurance and employer, including the proper insurance forms, filled in and signed, by the insured parent or guardian. We will require your portion of the charges, which your insurance company will not cover, including all deductibles and estimated patient portion (co-payment), at the time service is rendered. Your insurance policy is a contract between you and your insurance company – we are not a party to that contract. If your insurance company should not pay, any balance is ultimately your responsibility. We expect payment in full after 45 days from the time service was rendered.
PATIENTS WITHOUT INSURANCE
It is our policy to receive full payment at the time service is rendered. For your convenience, we accept most credit cards. We understand that some patients have special needs. If the above is unsuitable, you must make arrangements with the Account Manager.
DELINQUENT ACCOUNTS
For orthodontic services, payments are automatically withdrawn from the credit card the patient permits on a monthly basis. Any account that has had no payment for 30 days is considered delinquent and may be subject to 1.5% monthly service charge. If any account has had no payment over 60 days, it may be subject to outside collection action or turned over to our attorney; small claims court action may be taken. If this account is assigned to a collection agency or an attorney, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collectio