Patient Privacy Consent Form
Dental Insurance Guidelines
Dental insurances may provide partial coverage for your treatment fees. As a courtesy to you, we are happy to assist you by submitting the necessary dental insurance forms on your behalf. Most dental insurance fillings take a greater amount of effort and time to complete as compared to any other medical insurance plans; as such it is crucial to be aware of the following:
- The insurance relationship constitutes an agreement between the carrier, the employer, and the patient. Our dental office is not a party to that contract. As such, we can make no guarantee of actual coverage or payment.
- Insurance companies base the amounts they pay on restrictive fee schedules, regardless of what the actual fee might be. Not all dental services that are necessary for proper dental health are a covered benefit in all contracts. Plans vary depending on what type of plan your employer has purchased for you.
- Deductibles and co-payments are built into most plans and their required payment is strictly regulated by state law. We require full payment of this portion on the day services are rendered. Financial assistance is offered through Citi Health Card and Citibank. Please make prior arrangement with the front office staff if you would like to take advantage of their various interest free options.
- Your Employee Benefits Director can help you become familiar with your plan and its restrictions.
Monthly statements will be mailed out to your address on file. It is your responsibility to keep us appraised of any changes in order to prevent unforeseen situations. Payment in full is due upon receipt of the statement. If full payment is not received, we will make one attempt to contact you by your email and after 90 days your account will be reported to a collection agency. We encourage you to contact us to discuss any billing issues and to contact your insurance company with any coverage issues that you might encounter. In cases of dispute with your insurance carrier, the disputed amount is due and payable by you. Once the issue is resolved, any monies recovered from your insurance company, will then be reimbursed to you.
Our responsibilities:
- Complete insurance claim forms and submit to your carrier within 24 hours of treatment.
- Use current American Dental Association coding for correct reporting of procedures.
- Accept direct payment from your carrier and keep track of balances.
- If necessary, re-file your insurance a second time within a 30-60 day period.
Your responsibilities:
- To pay fees not covered by your plan at the time of treatment or as otherwise arranged.
- To provide our office with necessary information concerning your insurance coverage to allow correct filing of claims.
- To understand that your plan is a contract between you, your employer, and the insurance carrier. Our office will do all we can to facilitate claims payment, but we do not have the power to force your insurance company to pay.
- To pay any account balance not paid by insurance after 30 days and after 2 billing attempts.
Please know that we will do everything possible to see that you receive the full benefits of your insurance policy.
Appointment and Financial Guidelines
We believe in the value of clear communication, as well as mutual understanding and respect. We also believe that our patients would best be served if they know and understand our appointment, financial, and insurance guidelines in advance of their treatment. Below you will find these guidelines outlined for you. Should you have any questions about any of these procedures or any proposed treatments, please feel free to discuss them with us as we welcome any concerns that you may have.
Appointment Guidelines:
We desire, as well as strive to provide only high quality dental care with individual attention, all in a timely manner. In order to achieve this goal, prior to your arrival, we pre-plan your visit and prepare our staff to treat you with courtesy and professionalism. We only ask that you do the same. Please let us know in advance, should your plans happen to change and/or you know that you will be coming in either late or unable to attend your planned visit at all.
Your appointment time has been reserved especially for you and we strongly encourage all patients to keep their appointments.
Please be aware that any last-minute appointment changes will have an adverse effect on other patients as well. Last-minute appointment changes means that other patients that could have been seen but were denied and scheduled to a different time period due to the fact that we committed ourselves to accommodate you instead, will also not be seen as well.
We understand that sometimes changes to your schedule are unavoidable, however in order to avoid the $75 cancellation/change fee, we do require at least 48-business hours of notice.
Every effort is made to send you a courtesy reminder. When you receive our reminders, we ask that you respond and acknowledge the receipt of those reminders. If we are unable to contact you directly, your appointment card/courtesy reminder will serve as confirmation of your appointment and implies your obligation to be present at the pre-arranged date and time.
Financial Guidelines:
New Patients: Until we have verified the necessary accounting and insurance information, all treatment rendered on the first visit must be paid in full at the time of service. We happily accept cash, personal checks, or credit cards (MasterCard, Visa, American Express, and Discover.)
Established Patients: All of our fees or co-pays less than $300 will be due and payable at the time treatment is rendered. For fees and co-pays over $300, we have several financial options available. These will be reviewed with you in a separate document.