{"id":43,"date":"2013-11-14T13:37:07","date_gmt":"2013-11-14T13:37:07","guid":{"rendered":"http:\/\/192.185.121.75\/~dentist\/?page_id=43"},"modified":"2024-11-01T13:06:58","modified_gmt":"2024-11-01T13:06:58","slug":"forms-and-financial-information","status":"publish","type":"page","link":"https:\/\/pediatricdentistryofsouthcharlotte.com\/forms-and-financial-information\/","title":{"rendered":"Forms and Financial Information"},"content":{"rendered":"\n<h1>\n\t\tForms and Financial Information\n\t<\/h1>\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pediatricdentistryofsouthcharlotte.com\/wp-content\/uploads\/2013\/11\/forms.jpg\" alt=\"forms\" itemprop=\"image\" height=\"473\" width=\"360\" title=\"forms\" onerror=\"this.style.display='none'\"  \/>\n\t<h2>USEFUL FORMS:<\/h2>\n<ul>\n<li><a href=\"https:\/\/pediatricdentistryofsouthcharlotte.com\/wp-content\/uploads\/2013\/11\/PDofSCNewPatientReg.pdf\" target=\"_blank\" rel=\"noopener\">New Patient Registration Form<\/a> (PDF Document)<\/li>\n<li><a href=\"https:\/\/pediatricdentistryofsouthcharlotte.com\/wp-content\/uploads\/2013\/11\/PDofSCMedDentHx.pdf\" target=\"_blank\" rel=\"noopener\">New Patient Medical and Dental History<\/a> (PDF Document)<\/li>\n<\/ul>\n<h2><strong>Financial and Insurance Information<br \/>\n<\/strong><\/h2>\n<p>We appreciate you allowing us to provide dental care for your child, and our financial policy is designed to assist you in obtaining the highest quality dental care for your child.\u00a0 Every effort will be made to provide a treatment plan which fits your timetable and budget.\u00a0 We wish to attract parents to our practice that take an active role in their child&#8217;s dental health and remain financially responsible.\u00a0 Because we value our relationship with you and believe that the best relationships are based upon understanding, we offer these clarifications on methods of payment &amp; insurance reimbursement.<\/p>\n<h2><strong><em>Payment Policy<\/em><\/strong><\/h2>\n<p>For patients with dental insurance, we will work with your insurance company to estimate your benefits.\u00a0 On the day of service, you will be required to pay only the portion of the professional fees that we anticipate will not be covered by insurance. \u00a0For your convenience, we offer the following methods of payment:\u00a0cash, debit cards, most major credit cards, and CareCredit.\u00a0 Any amount not paid by your insurance company at 60 days from the date of service will be due in full from you at that time.\u00a0 For us to be able to provide this service, we will request a credit card at your first visit, and any amount unpaid at 90 days will be charged to this credit card. \u00a0Of course, we will continue to work with you to resolve your insurance claim appropriately.<\/p>\n<p>For patients without dental insurance, payment in full for professional services is due at the time dental treatment is rendered.<\/p>\n<p><strong>Please note:<\/strong> <em>we no longer accept cash at this office.<\/em><\/p>\n<h2><strong><em>Dental Insurance<\/em><\/strong><\/h2>\n<p>We are dedicated to providing all our patients with the <em>finest treatment available<\/em> and base our treatment recommendations on what will be best for your child and not what your insurance company does or doesn&#8217;t pay.\u00a0 Please note the following in regards to your dental insurance coverage:<\/p>\n<ol>\n<li>We must emphasize that as a health care provider, our relationship is with you and your child, not your dental insurance company.\u00a0 Your dental insurance is a contract between your employer and the insurance company.\u00a0 Most plans routinely pay between 50-80% of the average total fee for a covered treatment.<\/li>\n<li>As a courtesy, we will be happy to file for your insurance benefits, though we are not obligated to do so.\u00a0 Because your dental insurance plan is a contract between you, your employer and the insurance company, some carriers will not reimburse this office.\u00a0 In this instance, you will be responsible for the full cost of the visits at the time services are provided and your insurance company will send you the reimbursement check directly.<\/li>\n<li><strong>Any amount determined to be not covered by your insurance company is payable at the time services are rendered<\/strong>; these fees may include deductibles, co-payments, or certain procedures that are not covered by your insurance policy.\u00a0 Unfortunately, some of the services that we may recommend for your child will not be covered by your specific dental policy.\u00a0 Our primary goal is to treat your child using the <strong>best<\/strong> possible materials, supplies, and medications within a safe and non-threatening environment and not necessarily in the cheapest manner, which can be the goal of insurance companies.<\/li>\n<li>We allow a maximum of 60 days for your insurance company to clear account balances.\u00a0 <strong>Any unpaid portions will be due in full, by you, after this period.\u00a0 <\/strong>Any amount still outstanding at 90 days will be charged to your credit card, and will be subject to a finance charge.<\/li>\n<li>Our office <strong>does no<\/strong>t determine your dental benefits.\u00a0 Your employer chooses a particular policy and if you are unhappy with it&#8217;s specific coverage, this should be brought to your supervisor&#8217;s attention.\u00a0 Only your employer can adjust benefits or change policies.<\/li>\n<\/ol>\n<h2><strong><em>Financing Programs<\/em><\/strong><\/h2>\n<p>To help provide cost-effective care to our patients, we work with CareCredit, a healthcare lender, to offer short &amp; long term financing programs for dental treatment.\u00a0 Please feel free to inquire about these various payment programs.<\/p>\n<h2><strong><em>Financial Obligation<\/em><\/strong><\/h2>\n<p>After attempts to collect outstanding funds and a 90 day grace period from time of service, parents\/guardians not fulfilling their financial obligation will be sent to collections, as stipulated by our accountants.<\/p>\n<p>Prior to completing any treatment, we will provide you with a cost estimate indicating our total fee, what we anticipate your insurance coverage to be, and your estimated out-of-pocket portion.\u00a0 Please remember that this is only an estimate based upon generalized information provided by your dental insurance company.\u00a0 An additional billing or possibly a refund may be subsequently required, should the information provided be inaccurate.<\/p>\n<p>We will always do our best to maximize the insurance benefits that you are eligible to receive and we appreciate your prompt settlement of any charges that may be incurred during your child&#8217;s treatment process.\u00a0 We look forward to years of close association with you, as we work together to care for your child&#8217;s oral health!<\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>Forms and Financial Information USEFUL FORMS: New Patient Registration Form (PDF Document) New Patient Medical and Dental History (PDF Document) Financial and Insurance Information We appreciate you allowing us to provide dental care for your child, and our financial policy is designed to assist you in obtaining the highest quality dental care for your child.\u00a0&hellip;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-43","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Financial Information and Forms<\/title>\n<meta name=\"description\" content=\"Looking to visit Pediatric Dentistry of South Charlotte? 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