Patient Financial Resource
Below is a resource for you to better understand how we utilize insurance benefits, the payment options we offer and responsible party information. Please ask if you have any questions about the information below.
Participating Insurance Companies—We participate with certain insurance companies and accept their payment as payment-in-full, excluding any copayments or deductibles indicated in the contract you have with your insurance company. We will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible. We advise all or our patients to read through their insurance contract so they can have the knowledge and understanding of the plan prior to treatment.
Non-Participating Insurance Companies - We accept most insurance plans even though we are not considered to be a participating provider. This means that you will be responsible for your copayments, deductibles and any difference between our fees and the fees your insurance company chooses to accept. We will treat your insurance the same as we treat an insurance plan we participate with, meaning, we will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible.
No Insurance Coverage-We offer payment plans designed to fit your personal needs. We also accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. If you are without insurance, we do appreciate payment at the time of service. If a payment plan is needed, we will work with you to find the best option that fits into your budget.
Regarding Multiple Dental Plans-Secondary insurances are a great asset! We will submit claims to both your primary and secondary insurance plans to maximize the most of your insurance benefits. Sometimes, two insurance plans may not coordinate benefits due to a non-duplication clause or coordination of benefits clause. We will do all we can to find out this information for you prior to treatment, and we do advise our patients with dual insurance to also find this information out for themselves so they know what to expect from the insurance prior to treatment.
Responsible Party-Once our patients reach the age of eighteen (18), they are considered adults and therefore, responsible for their account. Patients seventeen (17) and younger are considered minors. A parent/legal guardian is responsible for treatment and financial decisions. In the event that parents are divorced, the parent that accompanies the minor to their appointment is responsible, regardless of the divorce decree.
I hereby authorize Harmony Dental to release information acquired in the course of the examination and/or treatment for insurance and/or legal purposes. I understand the information presented to me and that I am financially responsible for the services I choose.
Acknowledgment of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Harmony Dental types of uses and disclosures of my protected health information that might occur in my treatment, payment or services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
Harmony Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
ADDITIONAL DISCLOSURE AUTHORIZATION
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)