Virginia Dental Group PLLC Office Policy
*PRACTICE STANDARD TERMS: Payment for services rendered is due in full at the time of service. Our office accepts cash, personal checks (with valid driver’s license), and credit cards (VISA, MASTERCARD, and DISCOVER, AMEX, and CARE CREDIT). There is a $35 returned check fee due and payable from you for each check payment returned to us by your bank.
*PRACTICE FINANCIAL TERMS: Your insurance is a contract between you and your insurance company. As a courtesy to you, we can bill your insurance carrier, provided proper filing forms is provided to us. We can also assist you in billing your secondary insurance carrier, if applicable, and in researching unpaid claims. As a courtesy to you we will file 3 appeals to your insurance company requesting benefits. Preauthorization forms are not a guarantee of payment therefore we will not submit one to your insurance, every effort will be made to closely estimate your copayments and deductibles which are due at the time of service, but the ultimate responsibility for any unpaid balance rests on you. Your co-payment will be estimated and is due at the time of service unless other arrangements are made with our admin team. Unless we are a participating provider with the carrier, any secondary coverage is the responsibility of the insured. • If your insurance company has not made a payment within 60 days of billing, 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. Again, unless we are a participating provider with the carrier, any secondary coverage is the responsibility of the insured. You are responsible for any and all outstanding balances over 90 days. Accounts over 120 days will be forwarded to a third party collections agency in efforts to collect past due balance. A non-refundable fee of $75 will be added to all balances sent to third party collections.
PRACTICE APPOINTMENT TERMS: As a multi specialty practice quality and patient care, comfort, and quality is our goal! Therefore we require at least 48 hours notice when changing an appointment. There is a $50 charge fee for every hour for missed appointments without 48 hour notification. A payment minimum of 30%non refundable of the total treatment total is required when reserving specific dates for aesthetic, surgical, major restorative and orthodontic procedures. We kindly request that you complete all forms sent you 1-2 days prior to your visit. Late arrivals or delays due to incomplete forms are subject to a $35 late fee thank you for your cooperation.
Our goal is to provide high quality care to our patients and respect their schedule as well. In fairness to other patients, and the office staff, we require advanced notice when changing or cancelling an appointment.
When you schedule an appointment, we reserve that time and prepare in anticipation of serving you. If you should need to reschedule, we kindly request that you contact us with advanced notice. We understand that conflicts arise; however failing your appointment or canceling without adequate notice more than once may result in a charge.
Patients who continue to no-show and/or cancel without notice may be dismissed from the practice and asked to find another dentist.
Any patient who is late may be considered a “no show” for their appointment and may need to be rescheduled.
As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible.
SIGNIFICANT EXPOSURE - Section 32.1-45,1(A) and (B), Code of Va. (1950, as amended) provides that in the event of significant exposure (e.g. needle stick), consent for testing for Human Immunodeficiency Virus (HIV), Hepatitis B Virus and Hepatitis virus is considered to have been given by the patient and /or healthcare worker thereby granting the Hospital the right to perform such tests. Test results are confidential and can only be released in accordance with applicable laws and the policy of the local hospital. I authorize and release information and payment of my dental benefits to the dentist. I have read and understand fully my financial options and obligations. I understand that in the event my account becomes delinquent I will be responsible for any collections, costs and any other charges incurred to collect this account. Additionally, by signing this form I hereby authorize Virginia Dental Group PLLC to process Credit Card transactions initiated by me either by mail or phone and authorize my credit institution to pay
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