Forms

 

Welcome Letter

Please DOWNLOAD our welcome letter to find out more about your first appointment at our office. 

 

Medical History Form

Please DOWNLOAD and fill out the Medical History Form so we know of any potential issues with your child.

Financial Agreement

Please DOWNLOAD our Financial Agreement In order to clarify and agree on methods of payment.

 

Treatment Consent

As a parent/guardian, you have the right to be informed all of the information regarding your child’s care.  

HIPAA Authorization

Please DOWNLOAD the HIPPA form for authorization release of identifying health information.

 
Love this place! Always amazing with my kids. My 5 year old had to get several fillings and all she can talk about his the new hearts on her teeth. Said it didn’t hurt at all.
— Emma B., customer since 2012

Office Policies:


Scheduling Appointments

New Patients New patient appointment usually involves filling out medical health and other forms, getting to know our office, tell-show-do approach for the kids to get familiar with our procedures, and an information session for the parent and the patient with the doctor and the staff members.
Younger Children such as preschoolers should be seen in the morning because they are less tired and we typically are less busy when older children are at school. This way we can make their appointments easier and more successful.

Treatment appointments with multiple fillings, or crowns, or appliances will also be encouraged to be scheduled in the morning for the same reason. We will provide you with a school note and dental appointments are an excused school absence.  Older middle school and high school students can be seen in the afternoons if they do not have dental anxiety.

Oral or IV Sedation Appointments will be done in the mornings because children must be without food or drink that. We also want to give them the rest of the day to recover from the sedation medications that they will take in the morning.

"No Show" Appointments

Since appointed times are reserved exclusively for each patient we ask that you please notify our office 24 hours in advance of your scheduled appointment time if you are unable to keep your appointment. Another patient who needs our care could be scheduled if we have sufficient time to notify them. We realize that unexpected things can happen, but we ask for your assistance in this regard.
Our fees for missing an appointment without a 24 hour notification are as follows:
•    First missed appointment - $25 per child
•    Second missed appointment - $50 per child
•    Third missed appointment - $50 per child and dismissal of the patient from the practice
We regret having to make such rules, but we need to ensure that our patients are taken care of in a timely, caring and efficient manner.

Parental participation in the dental visit

We welcome parents to our initial exam appointment, to our consultation area following each appointment, and to visit our office for an office tour. We believe that parents are part of children's dental experience and our goal is to make dental visits easy, pleasant and memorable. We are all highly experienced in helping children overcome anxiety. Studies and experience have shown that most children over the age of 3 react more positively when permitted to experience the dental visit on their own and in an environment designed for children. Therefore, we try different approaches that will make your child most comfortable in our office.
It is very important however, that you do not leave the office during your child’s dental treatment. Situations may arise where we must speak to the parents about changes in treatment or emergency situations.

Finances

Payment for professional services is due at the time dental treatment is provided. Any amount over your insurance allowance will be collected on the day of treatment. Every effort will be made to provide a treatment plan which gives your child the best possible care and fits your timetable and budget. We accept cash, debit cards and most major credit cards. We do not take personal checks.

Our Office Policy Regarding Dental Insurance

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you as a courtesy. HOWEVER, WE ARE NOT A PARTICIPATING PROVIDER ON ANY DENTAL PLANS. THIS MEANS YOU ARE RESPONSIBLE FOR THE DIFFERENCE BETWEEN OUR FEE AND THE INSURANCE ALLOWABLE FEE.
You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. Your insurance might pay less or more than what we estimate, but because we are NOT IN NETWORK, we will not know for sure until we receive the payment.  Therefore, we are doing our best to give you the best estimate, but you might get a bill or a check for the discrepancy. By law, your insurance company is required to pay each claim within 30 days of receipt. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 60 days a finance charge of 2% will be added to your account each month until paid unless other arrangement with our office have been made. 

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can assist you in estimating your portion of the cost of treatment; we at no time guarantee what your insurance will or will not do with each claim. 

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Insurance Facts:

Fact 1 - NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is meant to be an aid in receiving dental care. We consider it a “coupon” or a “discount”. Many patients think that their insurance pays all dental fees, but most plans only pay between 50%-80% of the average total fee.

Fact 2 - BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee ("UCR") used by the company.
A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists charge for a certain service. This is simply is not accurate.

Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely. The insurance company arbitrarily chooses a level they call the "allowable" UCR Fee. These "allowable" fees are set by the insurance company so they can make a net 20%-30% profit on their clients.

Unfortunately, insurance companies imply that your dentist is "overcharging" rather than say that they are "underpaying" or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.  Your insurance provider/company choses a plan for all the participants and talking to the HR can sometimes help you attain a better plan.

Fact 3 - DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED
When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00 for the insurance company to pay. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 to be paid by the patient. Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.

MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.

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