Insurance and Financial

Dental Practice Financial Policy

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Financial responsibility on the part of each patient must be determined before treatment.

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As consistent with applicable laws and the policies of the patient's applicable dental insurance or other third-party payer coverage, we require the following:

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All emergency dental services and any dental services performed without previous financial arrangements must be paid for at the time services are rendered.

All dental services are charged directly to the patient and the patient is personally responsible for payment of all dental services, even if the patient carries dental insurance. This office will, as a courtesy, help prepare the patient's insurance forms and may assist in making collections from dental insurance companies, and will credit any collections from insurance to the patient's account. It is your responsibility to thoroughly understand the coverage and exceptions of your particular policy. Coverage issues can only be addressed by your employer or group plan administrator. We cannot act as a mediator with the carrier or your employer.

 

Fee estimates for dental care can only be extended for a period of six months from the date of consultation.

 

Payment for services is due at the time of treatment, or if billed by this office, payment is due within thirty (30) days of billing.

A returned check fee of $40.00 (subject to change as bank fees increase) will be added to your account for any returned check. Before we accept another payment by check, the $40.00 fee plus full payment for the check that did not clear must be paid in cash, or by credit card payment.

 

Charges for services shall be as billed unless objected to, by the patient, in writing, within the time payment is due.

 

Outstanding balances on your account are discouraged, and must be cleared in a timely manner. Delinquent balances over 90 days old will be referred to a collection agency. All referred accounts are marked "Inactive". In order to have your account "Reactivated", and continue to receive dental treatment in our office, the total account balance has to be paid in full before appointments can be made and your account and patient status be reactivated. All balance will do before any treatment is complete.

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HIPAA - NOTICE OF PRIVACY PRACTICES

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I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Continuity of care.

Obtaining payment from third party payers (e.g. my insurance company)

The day-to-day healthcare operations of our practice.

Electronic Communications used for appointment notifications, patient communications, practice promotion and any requested information on your behalf.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

This consent will continue forever unless I cancel it by writing to: Chagrin River Dental 37241 Euclid Ave. Willoughby, OH 44094