Warr PDA Financial Policy
Thank you for choosing us as your child’s dental care provider. Our staff is committed to providing you with the best possible care. In order to achieve these goals, we need your assistance and understanding of our payment policy. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.
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Regarding Insurance
Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If you have primary/secondary dental insurance, we ask that you pay any deductibles and co-pays the day of appointment. Please be aware that we are only able to estimate what your insurance coverage may be, and that the actual patient portion may be more than we expect. If you are deemed ineligible for your insurance benefits at the time of service, you are responsible for payment of services. Please be aware that some, perhaps all, of the services provided may be non-covered services and not considered reasonable and customary under the terms of your insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is the usual and customary fee for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Failure to pay our office may result in actions such as collections, legal actions, or the reporting of negative information to credit reporting agencies.
We are out-of-network for Blue Cross/Blue Shield and Delta Dental. Payment is sent directly to the policy holder (parent or guardian). For those patients, payment is expected in full on the date of service. As a courtesy, we will file services to your insurance and the check will be mailed to the policyholder (parent or guardian).
It is the responsibility of the policy holder (parent or guardian) to provide us the Explanation of Benefits in order to file secondary if primary is Delta Dental or Blue Cross/Blue Shield.
Billing
In an effort to ensure clear and precise billing:
a) Upon completion of scheduled visit an itemized statement will be available for your review but will not reflect any insurance payments that our office will file on your behalf
b) Once insurance payments are applied to your account an itemized statement will be e-mailed to reflect current balance due. Any outstanding balances are due within 30 days of updated billing
c) Non-compliance of payment will result in collections
d) The fee for paper statements is $2.00 per statement
Collections
All accounts which have not been paid will be handled by a collection agency that will pursue you for reimbursement. This can negatively impact your credit history and limit the treatment your child can receive at our office.
By signing below, you are authorizing us to call you at any number you provide including calls to cell, business phone, and any emergency contact listed. We or our agents may contact you by telephone and/or e-mail regarding your account.
Regarding Payment
We accept the following forms of payment: Cash, Personal Check, American Express, Mastercard, VISA, and Discover. For those patients who do not have dental insurance, we offer a 5% discount.
We are sensitive to the fact that some patients may require alternate payment options, please ask about Care Credit financing options. We do not offer in-office payment plans.
If a check payable to our office is returned to us due to insufficient funds or for any other reason, you are responsible for the remaining balance and a $25.00 return check fee within seven (7) days.
Refunds
Refunds for overpayment will be sent after all treatment is completed and insurance has paid in full.
Minor Patients
The adult accompanying a minor (parent or guardian) are responsible for full payment at the time of service. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized by an accepted method of payment.
Appointments
Appointment times are reserved especially for your child. If you must change your appointment time, we ask that you notify us at least 24 hours in advance or a $50.00 broken appointment fee may be assessed.
I have read and understand the office policy stated above and agree to accept responsibility as described. I understand that refusal to sign may impact the care of my child.