By signing below, I confirm that I have read, understood, and agree to the following terms:
General Responsibility:
Patients are responsible for understanding their insurance policy's coverage, limitations, and any remaining balances owed. Final treatment costs are subject to verification of insurance coverage and benefits at the time of service.
Patient Balances:
Payment for all services is due in full immediately after treatment is provided. If a balance remains, a statement will be issued, and payment must be made in full by the due date specified on the statement. Accounts exceeding 90 days past due may be referred to a collections agency. Future non-emergency appointments will be canceled until the balance is paid in full.
Appointment Policy:
Appointment times are reserved specifically for your child. To ensure availability for other patients, please provide at least 24 hours' notice for cancellations. A $35 missed appointment fee will apply for each child if notice is not provided.
Returned Checks:
A fee will be charged for any returned checks. The fee must be paid and the account balance settled before further services are rendered.
Dental Insurance:
Insurance estimates provided by our office are based on information you supply. Final patient responsibility may change depending on the insurance provider's determination, benefits used at other offices or during the year, or changes to your coverage. Failure to provide us with correct, active insurance information at the time of appointment may result in our inability to submit treatment charges to your insurance company. Submitting claims to your insurance provider is a courtesy our office provides, not an obligation. Predeterminations and estimates are not guarantees of payment. Patients are ultimately responsible for balances not covered by insurance.
Treatment Adjustments:
Unforeseen complications or adjustments to the treatment plan during treatment may impact financial responsibility. Efforts will be made to communicate anticipated changes promptly, but some changes may be unavoidable.
Emergency Care Fees:
After-hours emergency phone consultation is provided as a courtesy. However, in-office after-hours emergency care incurs additional fees to cover the cost of opening the office, support staff, and other resources.
General Anesthesia Services:
If your child requires treatment under general anesthesia, there are additional financial considerations outlined in a separate document that will be provided to you for review.
I understand and agree to the above financial policies for payment of professional fees. I acknowledge that I am ultimately responsible for all fees incurred for services rendered to me and/or my family.