Financial & Appointment Policies
Pediatric Dentistry Specialists, P.C. is a fee for service office. Payment for services are due
in full and is expected at the time services are provided. The parent/guardian that
accompanies the child to the appointment is responsible for payment, unless payment is
arranged prior to the appointment. Cases of divorce or other custody disputes, regardless of
divorce decree are no exception.
Patients with Dental Insurance
Although payment is expected at the time our services are provided; as a courtesy, we will
submit the dental claim for reimbursement back to you. Please know most insurance companies
do not inform us if they have issued you a check, therefore please follow up and call your
insurance company to inquire about the status of your claim if you haven’t received your
reimbursement or any correspondence from them. The insurance contract is an agreement
between you and the insurance company; we cannot guarantee your coverage or payments.
Our relationship is with you and your child, not with the dental insurance company. Questions
concerning insurance coverage should be directed by you to your insurance company. A service
charge of 10% of the bill or $10.00, whichever is greater, on any unpaid balance will be charged
on all accounts exceeding 60 days.There will be a $50 charge for returned checks.
PAYMENT FOR SERVICES IS DUE AND PAYABLE THE DAY OF SERVICE
Payment may be by cash, personal check, Mastercard, or Visa.
Appointment Policies
A set amount of time is reserved for each patient appointment in order to provide the best dental
care possible. We understand family schedules are busy and ask that you please call us as
soon as possible if you need to reschedule. We reserve the right to charge for appointments that
are canceled, missed, or broken with less than a 48 hour notice.
Arriving late to the appointment
We strive to be conscientious of your time and do our best to see patients at their scheduled
appointment times.Your child’s appointment has been expertly planned for the best delivery of
care in order to meet your child’s individual oral health needs. Please call the office to alert us if
you are running late. If you arrive 10-15 minutes late for your child’s appt, you may be asked to
reschedule.
I grant permission to Pediatric Dentistry Specialists, P.C. to contact me at any phone numbers to
discuss matters related to my child’s oral health and/or account. I accept financial responsibility
for this child. I authorize the release of any dental information necessary to process this claim
and all future claims. I will be responsible for reporting any changes in my child’s dental
insurance coverage. I will be responsible for any late fees due on my account.
I have read the above policies and agree to their content.
Signature of Parent/Guardian_________________________________
Printed Name of Parent/Guardian______________________________
Patient name(s):____________________________________________
_________________________________________________________
