Download office policies - Lowry Pediatric Dental Health

OFFICE POLICIES
CANCELLATION OF AN APPOINTMENT: Our office understands emergencies happen, and our patients
are not always able to keep their originally scheduled appointments. In order to be respectful of other
patient’s needs, please be courteous and call our office promptly if you are unable to attend an
appointment. This will allow us to offer your reserved appointment to a patient in urgent need of
treatment. Any appointment(s) not cancelled two business days in advance is subject to a $75
cancellation fee.
NO SHOW POLICY: A now show is an appointment that was not cancelled in advance. No shows
inconvenience other patients who need dental care and can cause the practice and the doctor to be idle.
This ultimately increases costs for everyone. A no show for a scheduled appointment will result in a fee
of $50 for every half hour of scheduled appointment time.
FINANCIAL POLICY: As a gesture of courtesy, our office is happy to submit insurance claims for your
child. Remember that your dental insurance is simply a contract between you, your insurance company,
and your employer; therefore, you are ultimately responsible for knowing the details of your insurance
coverage.
I have read and understand the above paragraph. ____ Initials
We will file your claim for no charge; however, we ask that our deductibles and your estimated portions
be paid as services are rendered. Although we gladly file dental insurance claims as a courtesy to you,
any and all account balances are ultimately your responsibility.
Please contact us if you make any changes to your dental coverage, so that we may keep accurate and
current records of your account and expedite reimbursement of your dental benefits.
Sixty days is the most we can wait for your insurance company to pay your account balances. After
those sixty days, we will need you to pay any unpaid bills that your insurance did not cover.
For your convenience, we accept cash, money orders, cashier’s checks, personal checks, Visa, Discover,
MasterCard, and American Express. All returned checks will be subject to a $25 fine. After our attempt
for collection is made, and a grace period of 90 days from the day of service, the parent or legal
guardian responsible for the account will be sent directly to the credit bureau to settle the financial
obligation. I agree to pay all finance charges, collection costs, attorney fees, and all other costs
associated with the collection of my outstanding accounts as allowed by law.
Signature: ____________________________(Patient, Parent or Guardian) Date: ____________
Lowry Pediatric Dental Health; 8111 E. Lowry Blvd, Ste 200, Denver, CO 80230; (P) 303.343.2803