Pediatric Dental Centers Financial Policy.
Effective Date: 07/23/2023.
Thank you for choosing Pediatric Dental Centers for your child’s dental care. We are committed to providing you with the best possible dental services while maintaining clear and transparent financial practices. This Financial Policy explains our payment and insurance procedures. By receiving dental services from us, you agree to the following terms:
Payment for Services:
1.1. Payment is due at the time of service unless prior arrangements have been made with our office. We accept various forms of payment, including cash, credit cards, and personal checks.
1.2. For services not covered by insurance or if you are a self-pay patient, a full payment is required at the time of service. We offer various payment plans and financing options; please inquire with our office staff for more information.
1.3. If your child has dental insurance, we will estimate your portion of the cost based on the information provided by your insurance company. However, this is only an estimate, and the final patient responsibility may vary based on your specific insurance plan.
2.1. We accept most dental insurance plans and are committed to helping you receive the maximum benefits available under your child’s policy.
2.2. As a courtesy, we will file insurance claims on your behalf. However, please understand that you are ultimately responsible for all charges not covered by your child’s insurance company.
2.3. If your child’s insurance company does not pay the estimated portion or denies the claim, you are responsible for the outstanding balance.
2.4. Any co-pays, deductibles, or non-covered services are due at the time of service.
Missed Appointments and Cancellations:
3.1. We understand that circumstances may require you to reschedule or cancel appointments. However, we kindly request that you provide us with at least 24 hours’ notice to avoid a missed appointment fee.
3.2. Missed appointments or cancellations without sufficient notice may be subject to a fee as determined by our office.
4.1. Accounts with outstanding balances beyond  days may be subject to collection efforts, and you may be responsible for any additional collection-related costs.
4.2. We reserve the right to suspend further treatment for patients with overdue accounts.
5.1. As the parent or guardian, you are responsible for all charges associated with the dental services provided to your child.
5.2. By signing below, you acknowledge and agree to the financial responsibility outlined in this policy.
We believe that open communication about financial matters is crucial for a positive patient-dentist relationship. If you have any questions or concerns about our financial policy, please feel free to discuss them with our office staff. We are here to help you navigate the financial aspects of your child’s dental care and provide a pleasant experience.
Patient Name: _______________________________________________
Parent/Guardian Signature: ___________________________________
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