OFFICE POLICIES
Alan Golshanara, D.D.S.
Our philosophy is to provide the highest quality of patient education and dental care to all of our patients. Our hope is by providing you the following information we can prevent misunderstandings to ensure you a positive experience. Please feel free to let us know if you have any questions or concerns.
EXPECTED PAYMENT
To keep our fees to you as low as possible, we ask that payment be made at the time of service. For your convenience an estimate for services will be prepared in advance of your appointment/s to ensure you opportunity to plan for your dental care. We believe whether you privately pay or have dental insurance to assist you, everyone deserves the care they need and want.
DENTAL INSURANCE
We are happy to file your dental claims to assist you in receiving the full benefits of your coverage. We request you familiarize yourself with your insurance benefits, and provide us the correct information to assist you with the submittal of claims. We will accept the estimated insurance payment directly from your insurance company provided payment is received from them within 45-60 days. Please realize that your insurance is a contract between you, your employer, and the insurance company; therefore, we cannot guarantee coverage and your assistance may be requested. Not all services are covered benefits in all contracts; therefore, you are ultimately responsible for the total amount of your dental fees. The treatment recommended for you is indicated regardless of your dental insurance benefits, deductibles, limitations, or maximums.
PAYMENT OPTIONS
For your convenience we provide a variety of payment options to help you receive the quality care you need to enjoy a healthy and confident smile. Please identify which form of payment is most convenient for you at the time of service.
PAST DUE BALANCES
If applicable balances owing from a prior visit where insurance is not pending, or an insurance payment has not been received within 90-days, or the account has been sent to collections is considered past due. Payment of any past due balance is required to be paid in full before incurring new charges. Balances over 90-days may be subject to a rebilling fee.
CANCELLATIONS
If you are unable to keep an appointment that has been reserved for you we request you provide us with a 48-hour advance courtesy notice. Early notification ensures that we can offer you a more convenient appointment and allows us sufficient time to accommodate the needs of another patient. We realize that emergencies do occur and we will be flexible under those circumstances. Please be advised that a cancellation fee of $50.00 to $100.00 may be incurred depending upon length of appointment when sufficient notice is not provided as requested.
CELL PHONES
We ask that cell phones and pagers be turned off at all times while in the treatment area. If being available for an emergency during your reserved appointment is necessary, please leave our office telephone number so you can be reached. Should an unfortunate emergency arise we would be happy to notify you in the treatment area immediately.
INFORMATION CHANGES
To ensure your records are current please notify us of any changes related to medical history, telephone numbers, address, employer or insurance information as they occur.
My signature indicates that I understand that policies as outlined and any questions I have with regard to office policies have been answered.
My signature indicates that I have reviewed the office policies with the responsible party and/or patient.
Customized by Dental Management Solutions, Inc. 2007-Revised
