OFFICE POLICY

1. When agreeing to the financial agreement (contract), please note that your monthly payment is due on the First or the Fifteenth of each month. Monthly payments with office payment plan will be made by automatic draft only. We have this program to make payments as easy as possible and eliminate any risk of late charges.
2. If payment has not been received in our office ten days after the due date and you are not enrolled in our late fee protection plan, or the draft to your account under that plan was declined, a non-refundable $35.00 late fee will be assessed on each past due payment. Our collections department will be contacting you to arrange payment of the past due amount and the late fee.
3. Late charges are applied to each outstanding payment.
4. If your account is 60 days past due, a dismissal letter will be sent via certified mail. This will terminate our responsibility to the patient. Further orthodontic treatment will have to be rendered by another orthodontist. However, if the patient finds alternate financing and pays the entire unpaid balance, as well as, outstanding late fees and charges, active treatment can be reinstated. If the patient prefers we can remove the braces with a fee. Fee will be determined by the office.
5. Our high tech treatment plans allow more time between appointments and reduces school and work loss. A monthly payment plan is a simple, convenient way to spread out the cost of orthodontic treatment; therefore it is still due each month even if there is no appointment during the month.
6. We reserve the right to extend the option to continue payments in the event treatment completes prior to the estimated completion date and/or contract agreement. In the event that the account has necessitated collection activity for delinquent payments, payment in full is required at the time appointments are established for the debanding sequence.
7. Any fees incurred in collecting a delinquent account will be charged to the responsible party for the account.
8. I understand that I am responsible for all fees at time services are rendered, regardless of insurance, including any legal court costs or agency fees incurred in the collection of this account.
9. There will be a $50.00 NSF charge for any checks or auto debits returned.
10. A minimum charge of $25.00 will be applied for any additional filing of insurance or special request forms and/or letters produced by our office.
11. 50% of the down payment will be refunded if the patient decides not to begin treatment after a contract has been signed for administrative fees.

Treatment Cooperation Policy

1. Successful treatment is dependent on the following:
(a) Patient cooperation with headgear, elastic wear and wear
(b) Proper oral hygiene
(c) Care of appliances; broken, lost or distorted appliances add to treatment time
(d) Keeping appointments as schedule (missed or changed appointments interrupt treatment progress)
(e) Eliminating foods and eating habits that break or distort the appliance
(f) Reporting broken or lost appliances promptly
Our services may be discontinued for lack of cooperation.

Appointment Policy

1.Appointments are normally scheduled at one-to-twelve week intervals. These appointments are reserved for our patients so that the best, most efficient orthodontic therapy can be provided. Therefore, some appointments must be during school hours. It is the patient’s responsibility to schedule his/her own appointments on a timely basis. These can be scheduled when leaving after each visit, and are therefore scheduled weeks in advance. One working day in advance cancellation notice is required to cancel an appointment. If an appointment during our “prime” time (7:30am-9:00am and 2:30pm-4:00pm) is cancelled less than one working day before the appointment you will not be allowed to reschedule during another “prime” time slot. If an appointment is missed, it is the patient’s responsibility to contact our office immediately to set up a new appointment.
Reappointment of the original date will reduce the selection of a convenient time. Missed or changed appointments must be rescheduled within one to two weeks of original appointment.

INSURANCE POLICY

1. Our office will assist you with insurance coverage by submitting the initial claim forms and with proper verification; we will accept direct assignment on full orthodontic treatment to make financing easier. An insurance account will be established and the amount of insurance benefits will be transferred from the patient account to the insurance account.
2. Our office will then be responsible for the periodic filing of insurance claims and the follow-up on payments. We are not responsible for disputing claims.
3. If for any reason during active treatment the insurance benefits decrease, change, or are terminated, the unpaid balance will be transferred back into the patient’s account and will be the responsibility of the patient
4. It is the patient’s responsibility to inform us of any change in coverage or company. We may need to ask the patient’s help in filling out the forms or making calls to the insurance company.
5. We reserve the right to refuse to process or accept insurance benefits at any time.
6. There will be a one-time fee for our office to process insurance paper work when we have not accepted assignment of the benefits.

Extra Charges Policy

1. Charges will be made for each missed or changed (in less than 48 hours) appointment longer than 10 minutes and/or in excess of 2 occurrences. Charges will be assessed by length of procedure and to be paid before next appointment.
2. Charges for breakages after 2 during active treatment are payable upon repair. Charges will be assessed by length of procedure to repair and to be paid at the appointment. For all replacement brackets there will be additional fees assessed per bracket.
3. If opted in for the Lifetime Retainer plan the following policy will apply
*Only a trutain (clear/plastic) will be given in place of the lost or broken removable retainer with a fee of only $25 for each trutain.
*If the initial contract fee was not paid out, the lifetime retainer policy will be null and voided.

Emergency Policy

1. Emergency appointments after school hours will consist of making patients comfortable. To service you with the best possible care, and ensure completion of a repair being done in one visit, repairs will be scheduled during school hours.
2. One of our assistants will be on call 24 hours a day you may call us at 337-577-8869. Many emergencies can be managed with a phone call; however we will be available to come into the office on weekends and weeknights to make patients comfortable. Repairs cannot be done at these hours.

Payment in full at Debond

1.The balance of your account is due before the braces are scheduled to be removed.

Dental Care Policy

1.General dental care and check-ups are the responsibility of the patient and your regular family dentist. We recommend that you see your family dentist at least every six months during active orthodontic therapy. If you have changed dentist or there has been a change in medical history it is the patient’s responsibility to notify our office as soon as possible.
These policies are subject to change at any time without written notice to current patients.
I have read the above policies and agree to abide by them.
Signature of Responsible Party
Date
Signature of Witness
Date