My Children's Dentist Office Policies
Cancellation Policy:
Your chosen reserved appointment time is very important to us. We understand occasionally there are unforseeable events that may require your immediate attention. this making it impossible to keep your appointment. However, whenever possible, we kindly ask that you give us 24 hour notice prior to your cancellation. If you are unable to keep your initial visit and no attempts were made on your part to to notify the office after the appointment was missed, your next available appointment may be four (4) months afer your originally scheduled appointment. Aftr two "no shows" (meaning not making it to your appointment and failure to give notice of missing the appointment), we may ask you to seek another dental provider.
The courtesy that you extend to us will assure that someone else can be seen in a timely fashion. In order for us to provide you with the highest quality standard of care and education for your child, we ask that you arrive on time for your appointment with the necessary paperwork completed. You will find a copy of forms available on this website for your convenience. We do our best to accommodate everyone, but this ca be done if we stay on schedule.
Insurance and Financial Information Policy
After your treatment plan is formulated, we will provide you with a written estimate of what your financial obligation will be in terms of co-pays (again no surprises). Although some individuals choose to defer treatment for their child until they know their exact benefits, we do not recommend this practice. Insurance companies can take up to three to four weeks to respond and cavities just get larger. All co-pays are due at time of service.
We are committed to providing you with the best possible care. If you have insurance, we are anxious to
help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. *Any portion not covered by insurance will be due at the time of service. We accept cash, checks, Visa and Mastercard. There will be a $35.00 charge for all returned checks. All balances older than 30 days will be subject to interest charges of 1.5% per month. We will gladly discuss your proposed treatment and answer any questions relating to insurance and finances.
You must realize, however, that:
1. Your insurance is a contract between you, your employer and insurance company. We are not a party to
the contract. We require that you bring your current copy of your insurance card to each appointment.
2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select
certain services they will not cover. We must emphasize that as dental care providers, our relationship is
with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend
to our patients, all charges are your responsibility from the date the services are rendered.
3. The parent that accompanies the patient to all dental visits is considered financially responsible
for the account. Our office policy requires that all children need to be accompanied by an adult at all
times in case of an emergency.
4. My signature confirms that I have been informed of my rights to privacy regarding my protected health
Information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).
If you have any questions about the above information or any uncertainty regarding insurance coverage,
PLEASE don’t hesitate to ask us. We are here to help you.
I have reviewed the foregoing policies of My Children's Dentist Professional Corporation and I agree to be responsible for all dental services not covered by my dental plan, unless the dental practice has a contractual aggreement with my plan prohibiting all or a portion of such charges. To the extent permitted under applicable law, I authorize release of any information relating to any claims.
Child’s Name________________________________________________________________________
Guardian Signature _____________________________________________ Date _______________
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