We are required by State and Federal laws, including the HIPAA Rules, to safeguard general and health-related information about you. We have created a Notice of Privacy Practices that explains how your protected health information is handled. The Notice of Privacy Practices is provided to patients (and/or authorized representatives) when they first become our patient.
This Notice of Privacy describes in detail how we might use or disclose your protected health information. The Notice also discusses your rights and our duties with respect to your protected health information. You have the right to review the Notice before signing this acknowledgment.
We are asking you to sign this form to show that we offered you a copy of our Notice of Privacy Practices. By signing below, you are only acknowledging that you were offered or received a copy of the Notice of Privacy Practices. You are not making a statement about the content of the Notice of Privacy Practices or about your agreement or disagreement with any portion of it.
Acknowledgement of Notice of Financial Policy
The following information is to inform you of our financial policy. If at any time you have questions regarding this policy, please do not hesitate to ask any member of our team. We are committed to providing the highest quality of care. Our fees are a reflection of the quality of care we provide. We continue our commitment by offering a variety of financial options to enable you to receive the dental care you need. We accept cash, check, VISA, MasterCard, Discover and American Express. We have also partnered with Care Credit to offer the flexibility of deferred interest and extended payment options.
Check policy: If your check is returned for any reason there will be a service fee.
will Wecommunicate all recommended treatment options and associated fees, prior to the start of treatment. Payment is expected at the time of
treatment. A delinquent account impedes our ability to provide you with the quality dental care that you deserve. It is our policy that the parent or guardian who accompanies a child to our office for treatment is responsible for payment of all services rendered.
Late Payment Policy: I understand any overdue and/or late payments may be subject to a SERVICE CHARGE OF 1.5% PER MONTH will be added to
the balance from the date of service.
We are committed to respecting your time and ask that you make every effort to keep the appointment time reserved exclusively for you. We understand there may be times you are unable to keep your appointment, however, any appointment missed may be subject to a missed appointment fee. Should you find it necessary to reschedule an appointment, please provide us with 24-48 hour notice to avoid missed appointment fee. As a courtesy to our patients with dental insurance benefits, we will submit your claim and provide any necessary information to assist you in receiving your dental benefits. We require any applicable deductibles and estimated patient portion be paid at the time treatment is rendered. We do not accept assignment of insurance benefits as a form of payment to help reduce your immediate out-of-pocket expense. We are participating providers in the Delta Dental Network; however we do not participate in any other PPO network plans at this time. If you have a direct reimbursement policy, payment in full is expected on the day of service and your dental plan will reimburse you. Providing us with your dental insurance carrier information will expedite the processing of dental claims.
Important Facts About your Dental Insurance: Dental insurance is a contract between the patient and the insurance company. It is a benefit to assist you with the cost of dental care. At no time should insurance benefits compromise your doctor's diagnosis or affect your choice in treatment.
It is your responsibility to understand the type of insurance you have and the benefits selected by you and/or your employer. You (not the insurance company) are responsible for the fees of services rendered.