Financial Policy

Appointments
We value the time you/we have set aside for your dental care. If you are unable to keep an appointment we would appreciate at least 48-hour notice. Patients who do not show up for 3 (three) appointments without notifying us in advance may be released from our practice. If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment. We strive to minimize any wait time; however, emergencies do occur and some patients may take longer than others. This may affect scheduled visit times. We appreciate your understanding.

Insurance Plans
It is your responsibility to keep us updated with your correct insurance information. Insurance cards should be available to be copied at every visit. If the insurance company you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement. It is your responsibility to understand your benefit plan with regard to, for instance, covered services. We will help you as much as we can, but if we cannot verify your insurance the day of service, we may have to reschedule your appointment unless alternate payment arrangements can be made. Eligibility with insurance is the responsibility of the patient.

Financial Responsibility
Co-payments are due at the time of service. You, the patient, are responsible for non-covered services (services not covered by your insurance plan). Self-pay patients are expected to pay for services at the time of the visit. If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement. Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 10 business days of your receipt of your bill. Any balance outstanding longer than 90 days will be forwarded to a collection agency. For scheduled appointments, prior balances must be paid prior to the visit. If a balance is due no appointments will be scheduled or services rendered. We accept cash, checks, Visa, Discover, and MasterCard credit and debit. A $25 fee will be charged for any checks returned for insufficient funds.

Financial Policy
I understand that I am responsible for payment of services rendered by White Rose Family Dental, LLC, and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize White Rose Family Dental, LLC to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

I affirm that the information I have given is correct to the best of my knowledge. All information herein will be held in the strictest confidence and it is my responsibility to inform White Rose Family Dental, LLC of any changes in my medical status. I authorize dental staff to perform the necessary dental services I may need, including x- rays, photographs, study models, or any aids deemed appropriate to make a thorough diagnosis of my dental needs.

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.