Sparkles Dentistry Financial Policy

Insurance Information: Sparkles Dentistry for Children is only in network with Delta Dental Premier Insurance. Delta Dental PPO subscribers must verify their own coverage by contacting your carrier or HR. If are covered by any other insurance, you must have OUT OF NETWORK BENEFITS. If you have any other plan, make sure it is not HMO or DMO. Sparkles Dentistry for Children will submit and process a claim for you and make every effort to ensure that the reimbursement is received provided you present the current DENTAL Insurance carrier. If you have more than one carrier, all insurance details must be provided on date of service. We are not responsible for coordinating if both plans are not provided on date of service. If insurance information provided is incorrect and reimbursement cannot be obtained in 90 days, the undersigned agrees to pay the full fee.

Current Dental Insurance information must be provided on the date of service. If insurance provided the day of service is incorrect, terminated, ineffective and a claim in unpaid as a result, the subscriber agrees to pay the charges for the visit and a claim form will provided to the subscriber. Future treatment will not be performed if an outstanding balance is unresolved. The subscriber is responsible for familiarizing themselves with their plan benefit details. If future treatment is planned, a form is submitted by our office to the insurance carrier and subscriber will receive pre-authorization details as negotiated between the subscriber’s employer and carrier. The office is not involved in setting copays and not responsible for negotiating or verifying details within the subscriber’s plan. 

Delta Dental Subscribers Only: I hereby authorize payment directly to Sparkles Dentistry for Children of the group insurance benefits otherwise payable to me. I understand I am financially responsible for any charges not covered by my insurance(s). I authorize release of any information relating to my dental benefits and claims.

Insured’s Signature Cancellation Policy: If you need to cancel or reschedule your appointment, I would like to remind you that we require 48 hours notice to avoid a $50.00 broken appointment fee. When appointments are cancelled without advance notice, it causes a gap in our schedule, which we are unable to fill.