As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Therefore, payment is due on the date that services are rendered. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.


Patients understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.  However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. The patient is responsible for ensuring proper insurance resolution and verification of in-network or out-of-network coverage.  If insurance does not pay expected amount, the patient will be held responsible for any outstanding balance on their account.  If claims are not paid by the patient's insurance company by the 61st day after treatment it will be billed in full to the patient. 


I understand that the fee estimate listed for any dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered by the Doctor to me, my spouse or my child, or at my request, I agree to pay therefore the reasonable value of said services to Valley Pediatric Dentistry at the time said services are rendered, or within five (5) days of billing if credit shall be extended.  I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees should any account due from me be referred to an attorney for collection.


I understand that at least 24 hours’ notice is required when cancelling any scheduled appointment. Failure to do so, after the 1st no show, will result in at $25.00 broken appointment fee or dismissal from this office as an active patient.  Emergency care will be provided as a courtesy for 30 days following inactivation.
RETURNED CHECKS:  There will be a $50.00 handling fee for any checks returned by the bank.


PAST DUE ACCOUNTS:  Any account 90 days past due will be sent to an attorney and or collections agency. In this event, the patient will be held responsible for the 34% collection fee associated with the collection. A billing charge of $5.00 and a service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.


DIVORCE:  In the event of of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of treatment costs, it is the authorizing parent's responsibility to collect from the other parent or have in-office documentation updated.


I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.

 

 

 

This practice, Valley Pediatric Dentistry, believes that matters pertaining to divorce, separation, and/or custody agreements should not enter into a child’s dental treatment.


The individual who is requesting the dental treatment is responsible for the account and payment of any ascertained fees.  This practice is not a party to your divorce agreement, you are.  The parent or guardian who COMPLETES and SIGNS our Consent for Services form will be considered the GUARANTOR REGARDLESS OF INSURANCE COVERAGE.


The responsibility for payment is with the parents or legal guardian of a minor child.  It is our policy to collect payment at the time of service from the parent, guardian or caretaker who brings the child in for the appointment.  This includes, but is not limited to, copay/coinsurance/payment in full.


“Joint custody” means that each parent has equal access to the child’s dental record. Without a court order, we will not stop either parent from looking at their child’s chart or obtaining their child’s records. If there is a dispute regarding custody, and a custody agreement has been reached, we will need to see documentation specifying the legal guardian.


We will not call the other parent for consent prior to treatment.


We will discuss with the accompanying parent information pertinent to the child’s history and/or present exam. It is the responsibility of the parents to communicate with each other about the patient’s care, office dates/visits and any other pertinent information relevant to the care of the child.


We reserve the right to charge an administrative fee for copying records.


Should the issues that come between parents become disruptive to our practice or impede the care of the child (children), we reserve the right to discontinue treatment.

 

 


If we have received all of your insurance information on the day of the appointment and have been able to verify eligibility, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file all insurance claims electronically, so your insurance company will receive each claim within days of the treatment.






PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. We also cannot be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.






We accept ALL private insurance, but are only an in-network provider of services for the following insurance companies:Delta Dental Premier ONLY.  Your plan may go by a different name or a smaller subsidiary and still be considered in-network. If network coverage impacts your selection of a dental office, you are responsible for verifying our participation in your plan.






Fact 1 - NO INSURANCE PAYS 100% OF ALL PROCEDURES



Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage, or the type of contract your employer has set up with the insurance company.






Fact 2 - BENEFITS ARE NOT DETERMINED BY OUR OFFICE



You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee ("UCR") used by the company. A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate.



Insurance companies set their own schedules, and each company uses a different set of fees they consider allowable. These allowable fees may vary widely, because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the "allowable" UCR Fee. Frequently, this data can be three to five years old and these "allowable" fees are set by the insurance company so they can make a net 20%-30% profit.




Unfortunately, insurance companies imply that your dentist is "overcharging", rather than say that they are "underpaying", or that their benefits are low. In general, a less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure, making your out of pocket expense higher. 



Fact 3 - DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED


When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.




MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address or a change of employment.