We welcome your child and family into our practice and are committed to providing your child(ren) with quality, compassionate and professional care.
The following polices have been established to facilitate a clear and professional relationship between you and our office.
Appointment Policy 48-HOUR NOTICE is required if you need to reschedule an appointment. If you cancel or reschedule LESS THAN 24 hours prior to a sedation, a hospital visit or on two separate occasions for other appointment types, we will not reschedule your child(ren) for additional appointments.
Missed appointments and/or untimely scheduling will cause your child to be inactivated as a patient in this practice. Inactivated patients will not be reactivated.
It is your responsibility to let us know of any changes in your contact information, including address, phone numbers, emergency contacts, etc. If your phone number changes and we are not able to reach you to reconfirm an appointment, YOUR APPOINTMENT WILL BE CONSIDERED CANCELLED.
A parent or legal guardian must accompany your child to a restorative appointment (anything that requires the use of analgesia/medication). Adults over 18 who are listed on the HIPAA form may accompany your child to a hygiene (cleaning & exam) visit.
Dental insurance is a contract between you, and/or your employer and your insurance company. We are not a party to that contract. Our recommendations for treatment are based on what will be best for your child and not what your insurance may or may not pay. If you have any concerns about your coverage, please contact your employer or your insurance company.
Though we are not obligated to do so, we will file your primary insurance claim as a courtesy to you.
Any amount estimated not to be covered by your insurance company is payable at the time services are rendered. Please remember this is only an ESTIMATE and not a guarantee of what your insurance will pay. You may owe more once the claim has been paid by your insurance.
We allow a maximum of 45 days for insurance reimbursement. After this period, any unpaid amount is due in full, by you, within 30 days. It is your responsibility to let us know of any changes in your insurance information.
If we do not have correct or updated information for filing at the time of service, we will not be responsible for unpaid claims. Some insurance carriers will only send reimbursement to you, not to our office. In this case, it is your responsibility to notify us immediately if your insurance company has sent our payment to you.
We reserve the right to require payment in full on day of service if we find that the insurance company repeatedly sends our reimbursement to you. There will be a $25.00 returned check fee for all personal checks returned for insufficient funds. After attempts to collect outstanding funds and a 60-day grace period from time of service, parents/guardians not fulfilling their financial obligation will be sent to collections. Overdue accounts greater than sixty days will be subject to all collections charges, interest fees (compounded monthly at 6%), legal fees, and any court costs associated with recovering funds due. You may also be prosecuted criminally by the City of Lynchburg.
If an employee of the practice is accidentally contaminated with your child’s body fluids (blood, saliva, vomit, mucus, etc.) your signature on this form gives permission for us to get your child’s blood drawn for infectious disease status, as defined by Virginia law and authorizes the testing facility to release the test results to the injured employee.