Thank you for choosing Your Expressions to serve your dental care needs. We provide high-quality dental care to our patients and are committed to your
treatment being successful. Please understand that your financial obligation is considered a part of your treatment. In the interest of good dental care practice it is desirable to establish a credit policy to avoid misunderstanding. To assist our patients, We offer the following methods for taking care of their account in our office.
On your first visit we expect you to supply our office with your insurance information and photo ID card. If any changes should occur during the time you
are a patient it is your responsibility to inform our office with any changes. Our office will not be responsible for claims submitted to insurance companies
by which you are no longer covered.
New patients are required to pay for services in full on their first visit. If the patient is a member of an HMO/DMO plan then the co-payment is due.
Patients are required to pay their deductible and co-payments at the time of each vist.
While we accept most insurance plans, and are happy to aid in submissions of your claims, it is your reponsibility to read your policy and be aware of services covered or not covered by your individual plan.
As a courtesy, we will gladly bill your insurance when you provide us with the current information and any necessary forms. Often times we are able to
contact your insurance provider prior to your appointment, and estimate your portion of the bill. We ask that you either pay your portion of the bill at the
time of service, or that a suitable written financial agreement be reached at the time of service. Even though you may have an insurance claim pending. You
will receive a monthly statement for the outstanding balance on your account until it is paid in full, We cannot accept responsibility for collecting an
insurance claim after 60 days or for negotiating a disputed claim. Insurance policies are a contract between you, your employer and the insurance carrier.
Please be aware that some, and perhaps all of the services rendered may not be covered under your individual insurance policy. You are ultimately
responsible for payment of your account.
If no payment is received on an account after two monthly statements our office will make every effort to contact the responsible party. If the party
responsible cannot be reached, a third bill will be sent indicating that “This will be the final notice for payment. If the party fails to contact our office after
receiving such notice, the account will be sent to a collection agency. Responsible party shall then be subject to collection agency charges.
Financial options are available to all patients. Please feel free to ask one of our office personnel.
Failed or Cancelled Appointments
If an appointment has been reserved for you, we kindly ask that patients give us twenty-four hour notice for cancellations; otherwise, we reserve the right to
charge a minimum of $45 per hour which is currently our broken appointment fee. If the appointment is with a specialist, the minimum fee is $50.00 per half
hour visits. The length of time reserved and the number of prior failed appointments determines your charge, We will not offer appointments to patients who fail
multiple appointments without having given us proper notice.
Estimates and Fees
After x-rays and examination, you are entitled to and should ask for an estimate of fees to cover your treatment, All estimates are based upon conditions
viewed at the time of diagnosis, unforeseen circumstances, such as pulpal therapy or cracked teeth could alter an estimated fee, It is customary to pay for dental
Services when they are rendered. There is a service charge on all unpaid accounts.
Delinquent accounts will have to be turned over to a Credit Reporting Collection Agency.
Notice of Privacy Practices (HIPAA)
A laminated copy of our office Notice of Privacy Practices (HIPAA) is avaliable in our office. You have the right to read our Notice of Privacy Practices
before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities and healthcare operations. Of the uses and
disclosures we may make of your protected health information and of other important matters about your protected health information. We encourage you to read it
carefully and completely before signing this Consent. Upon your request we will be happy to provide you with your own personal copy of our Privacy Practices.