If your account shows a balance, you will receive a statement each month, even if insurance has been submitted for you. All fees incurred with this office for services rendered will be due at the time of service unless previous arrangements have been made. If, for any reason, the bill is outstanding after 60 days, a late charge will be added to your balance in the amount of 1.5% per month which is an annual rate of 18%.
Insurance: We will be happy to complete and file your insurance forms to aid you in collecting full benefits according to your insurance plan. Patients who have dental insurance should be advised that the professional services rendered are charged to the patient and not the insurance company. You are responsible for any portion not paid by your insurance company, including any co-payments, deductibles, fees over your insurance company's UCR, etc. Even though an insurance claim has been filed, you will receive a statement each month if your account has a balance due. It helps us get your full benefits if you list complete dental insurance information on the previous page for all insurance plans.
Responsibility: We realize that many families are in a state of change. Divorced, separated, single parent and blended families are now common. In many of these families the question of who is responsible for the child's dental bills is uncertain. In the case of separated or divorced families we will need to have this form signed by the financially responsible party, otherwise the accompanying parent is responsible.
If you have any questions, please feel free to discuss them with the receptionists.
I have read the office policy and request that your office provide dental care. I authorize release of any information relating to any insurance claims. I hereby authorize payment directly to the dentist of the insurance benefits otherwise payable to me.
I understand that by signing this form I am hereby accepting responsibility for any and all fees incurred with this office.
Any amendments to this agreement must be discussed with the office manager and another form signed before any services are rendered. No handwritten amendments to this form will be accepted.
Consent for treatment
I am the parent/guardian of the minor child. I authorize examination of and treatment as necessary by or under the supervision of Dr. Kapil Davar or Dr. Vidhima Davar at Bel Air Pediatric Dentistry LLC. This includes exposure of radiographs (x rays) as necessary, cleaning, fluoride application, use of local anesthetic and/or nitrous oxide (laughing gas, if necessary), fillings/extractions/ crowns (if necessary) , reasonable restraint as needed, and use of appropriate medicaments and materials for such treatment.
I have read and understand the above information. By my signature below I consent to the treatment described above.
Broken Appointment Policy
We strive to provide excellent care to our families and reserve time specifically for your child to be seen. We understand and try to accommodate the schedules of parents and make every effort to see your child in a timely manner. Therefore we request that you extend us and our other parents the same courtesy by informing the office at least 24 hours in advance if you are unable to keep your appointment. There maybe a $30.00 missed appointment charge per child to your account if you do not provide our office 24 hours cancellation notice. We also reserve the right to terminate professional treatment of any patient who continually fail to keep their scheduled appointments.