Dear Parent or Guardian,
Thank you for choosing Toothworx for your child’s dental needs. We always strive to provide quality dentistry with compassion in a comfortable and friendly environment. We hope that you and your family will feel welcome at all times. We would like to acquaint you with our policies regarding dental insurance, financial arrangements and schedule changes.
We do not want finances to be an issue for our patients. We want you to feel comfortable with us, and that includes feeling satisfied with your financial arrangement regarding your child’s preventative and restorative dentistry. We encourage you to always read your initial emails that include an estimated copay, based on the insurance information we have on file and treatment requirements to our best knowledge. Unless financial arrangements are made prior to your appointment, payment is due at time of service.
*We accept Visa, MasterCard check and cash.*
Dental Insurance
• Dental Insurance - As a courtesy to you, if you have dental insurance we will complete your insurance form with all necessary information and submit it to the insurance company. Your co-payment will be estimated and is due at the time of service unless other arrangements are made with this office.
• If your insurance company refuses payment for one reason or another, the balance will become your responsibility. You will be billed for any balance due.
Insurance coverage is a contractual agreement between the insurance company and
you and/or your employer. We have no control over this relationship.
All accounts with an outstanding balance will receive a statement each month. We reserve the right to charge any outstanding balance over 30 days a finance charge of 1.5 (18% APR).
Please understand that we take the time that we have scheduled for your child and your child’s dental health very seriously and we hope for the same consideration. As a courtesy, we attempt to remind our patients of their appointment by email or phone call at 2 weeks prior, then 2 days prior and lastly, within an hour of their appointment and ask for a confirmation response as soon as possible. We reserve the right to charge for appointments broken without the proper 48 hours or 2 business day’s notice. We ask that a parent/guardian be present at every dental visit.
I authorize and release information about my child to Toothworx. I agree to the release of information regarding recommended treatment and treatment rendered to my child's insurance company. I have read and understand fully my financial obligations. I understand that in the event my account becomes delinquent more than 90 days, the account will be sent to the BCA and I will be responsible for any collections, attorney fees and any other charges incurred to collect this account. Additionally, by signing this form, I hereby authorize Toothworx to process Credit Card transactions initiated by me either by phone and authorize my credit institution to pay.