FINANCIAL FORM

  • Pediatric Dentistry

    Ph.609-200-5437

    Ph.732-737-7336

    littleteethprinceton@gmail.com

  • Please enter a value between 0 and 50.
  • Please read our financial policy below. We require you read and sign prior to any treatment. 

    FEES AND PAYMENT POLICIES
    In an effort to make needed services more affordable, payment for professional services is due at the time dental treatment is provided. If you have insurance, then your estimated co-­‐payment is due as service is rendered. If an account shows an overdue balance, future treatment may be delayed until balance is cleared. We accept checks, cash, Mastercard, Visa and American Express.
    APPOINTMENTS We ask for your utmost courtesy regarding your scheduled appointments. Please allow 24 hours prior to the appointment time if you must cancel or reschedule. We understand that unforeseen business and personal emergencies do occur; however, repeated last minute cancellations and broken appointments will incur a charge of $25. Most insurance companies will not reimburse the cost of a missed appointment.
    ABOUT INSURANCE
    Fact 1 – No insurance pays 100% of all procedures.
    Dental insurance is only meant to be an aid in receiving dental care. Many patients think that their insurance pays 100% of all dental fees. This is not true. Most plans only pay between 50-­‐80% of the average total fee. Your employer has determined the amount of coverage according to the contract set up with the insurance company.
    Fact 2 – Benefits are not determined by our office.
    Insurance companies often state that the dentist’s fee has exceeded the usual, customary, or reasonable fee (UCR). This statement is very misleading and inaccurate.
    The insurance company gathers data and arbitrarily chooses a level they call “allowable” UCR fee. The data is usually 3 to 5 years old, and the “allowable” fees are set by the insurance company so they can make a profit. Most dentists’ fees are higher than what the insurance company considers an average fee.
    We are pleased to bill these insurance providers directly – as long as we have been supplied with all the necessary subscriber information. Without the necessary insurance information, we cannot submit claims to them, and will therefore require payment in full at the time of service. An estimated co-­‐payment is requested at each appointment as service is rendered.
    Please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of fees for treatment. We at no time guarantee what your insurance will or will not do with each claim. We cannot be responsible for the accuracy of any insurance information. Your insurance company representative has provided this information to us. It is your responsibility to be familiar and understand your insurance policy and terms.
    You are responsible for payment of any balance due not paid by your insurance company, including any unpaid deductible amounts or if your plan only allows one fluoride application per year, etc.
    *THE PARENT WHO BRINGS THE PATIENT IN FOR TREATMENT IS RESPONSIBLE FOR ALL FEES INCURRED AT THE TIME OF SERVICES ARE RENDERED. WE CANNOT SEND STATEMENTS TO OTHERS/OTHER PARENTS.*
    I have read the above conditions of treatment and payment and agree to their content

     BY TYPING MY NAME BELOW I AGREE TO THE ABOVE FINANCIAL POLICY.