FINANCIAL, APPOINTMENT, AND INSURANCE INFORMATION

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PAYMENT POLICY

Payment is due in full at the time dental treatment is provided. For your convenience, we offer the following methods of payment: Cash, MasterCard, Visa,Discover, and Care Credit (see Financing Program below.)

DENTAL BENEFITS

We are dedicated to providing all our patients with the finest treatment available. We base our treatment recommendations on what will be best for your child, and not what your insurance company does or does not pay. Please note the following in regards to your dental insurance coverage:

1. We must emphasize that as a healthcare provider, our relationship is with you and your child, not your dental insurance company. Your dental insurance is a contract between your employer and the insurance company. Most plans routinely pay between 50% - 80% of the fee the insurance company sets, which typically are not the fees set by dental practices.

2. As a courtesy, we will file your insurance claim electronically on the day of service.

3. Any amount determined to be not covered by your insurance company is payable at the time services are rendered; these fees may include deductibles, co-payments, or certain procedures that are not included in your insurance policy. Unfortunately, some of the services that we may recommend for your child will not be covered by your specific dental policy. It is the parent/guardian policy to know your dental benefits. FOR ALL NON -COVERED SERVICES, WE REQUIRE YOUR CO-PAY OF THE TOTAL TREATMENT PLAN TO BE PAID ON THE DATE OF SERVICE. Any overpayment will be refunded to you upon receipt of claim payment.

4. OUR OFFICE DOES NOT DETERMINE YOUR DENTAL BENEFITS. Your employer chooses a particular policy and if you are not pleased with its specific coverage, this should be brought to your supervisor's attention. Only your employer can adjust or change benefits.

5. OUR OFFICE DOES NOT GET INVOLVED IN DIVORCE CASES OR CUSTODY ISSUES. It is the responsibility of the parents, grandparents, and/or legal guardians to address any issues with divorce cases or custody issues, prior to scheduling and payment for dental services rendered is expected.

If you do not have dental coverage, we may be able to providing assistance with your obtaining coverage. Please ask for details.

FINANCING PROGRAM

To help provide cost-effective care to our patients, we work with CARE CREDIT, a healthcare lender, to offer financing programs for dental treatment. Please feel free to inquire about this program. We are dedicated to providing all our patients with the finest treatment available and base our treatment recommendations on what will be best for your child and not what your insurance company does or does not pay. Please note the following in regards to your dental insurance coverage:

We strive to do our best to maximize the insurance benefits that you are eligible to receive and we appreciate your prompt settlement of any charges that may be incurred during your child's treatment process. If there is an unpaid balance after 30 days from the date of service, you will receive the first statement. If the account is 60 past due from the date of service, a late fee of $25.00 will be applied. If the account is 90 days late from the date of service, the account will be sent to collections along with a final late fee applied in the amount of $25.00. We strive to provide you and your child the concern, respect, and care that makes our office a comfortable and pleasant place to visit. In return we kindly ask for your consideration of our time. We request at least 48 hours notice to cancel or reschedule any appointment. Failure to comply with this policy may result in a $25.00 fee assessment.We look forward to many years of close association with you as we work to optimize your child's oral health.

APPOINTMENT POLICY

1. One [1] missed appointment, without 48 hours notice, will require a deposit to secure another appointment.

2. We require a deposit to hold appointments for dental treatment rendered via conscious sedation or general anesthesia.

3. Two [2] missed appointments, within one calendar year, will result in dismissal from the practice.

I have read, understood and had all questions answered about the financial policies, insurance policies, and appointment policies at Prime Pediatric Dentistry.