Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment. As a condition of the treatment performed by the providers of the office (Omni Family Dental), financial arrangements must be made in advance for the full cost of proposed treatment. The practice’s vitality depends upon payment for services as rendered, and it is the responsibility of the patient or patient’s parent/guardian to satisfy the costs incurred in dental care. Financial arrangements for each individual must be determined prior to any treatment.
PATIENTS WITH DENTAL INSURANCE:
We ask that you provide us with all of your insurance information a few days prior to your first appointment. In order to honor any insurance benefits, you must provide insurance identification, and we must be able to verify the current benefits available.
Your dental plan may or may not include benefits for services rendered in this office (Omni Family Dental). The benefits you receive are in accordance with your dental plan agreement, which is determined by either your employer or yourself.
Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes, but is not limited to, dental fees, surgical procedures, tests, office procedures, medications, and also any other services not directly provided by the dentist.
Our office will gladly submit your insurance claim. Please understand that your insurance is a contract between you and your insurance company. Professional services are rendered and charged to you, not your insurance company. Actual insurance benefits will be determined by the insurance carrier. Payment for the services is your responsibility.
We will accept the assignment of claims for primary insurance only. Secondary insurance would be charged to the patient upfront. We can refund once the primary and secondary claims are all processed and paid in full. All deductible and estimated fee amounts not covered by insurance are due prior to any treatment.
We do our best to give accurate estimates. Keep in mind that it is our best good-faith estimate, but you may be billed for services that your insurance company will not cover due to exclusions or plan limitations. Our office will not enter into a dispute with your insurance company over your claim. This is your responsibility and obligation.
OFFICE FEES (PAYMENTS):
We accept Cash, Zelle, Visa, Mastercard, Discover, AMEX, and CareCredit with Cherry. If you present a check for insufficient funds or stop payment on an issued check, you will be charged a $75.00 processing fee and be responsible for the entire balance. All dental services must be paid in full prior to the services being rendered for patients without a dental plan, unless otherwise specified.
Treatment Deposit Policy:
In order for us to ensure that every patient receives individual attention from our provider, we set aside dedicated time for each appointment. At the time of scheduling, a deposit or full prepayment will be due and will go towards the cost of your treatment.
All new patients are required to pay a deposit of $50 prior to scheduling any appointment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid in full prior to the services being rendered.
MISSED APPOINTMENTS:
Because chairs, personnel, and instruments are reserved exclusively for your appointment, if you break an appointment with our practice (Omni Family Dental), we ask for a 48-hour notice of cancellation or reschedule. If we do not receive a 48-hour notice, you may be charged a $75 fee for the scheduled appointment. This fee cannot be charged to your insurance company.
Please help us serve you better by keeping scheduled appointments. Please note: If you are late for your dental appointment by over 30 minutes, we may have to reschedule your appointment or have less work completed. In turn, if we are running late, we understand that you may need to reschedule. If you are habitually late, you may be asked to select another provider on your insurance plan.
Audio/Video Release Consent Form:
Omni Family Dental uses video and sound surveillance for the safety of all our patients and staff. By signing this form, you are aware of our use of surveillance in the office waiting areas only. You will not receive compensation for the use of your image, likeness, appearance, and voice now or in the future. Omni Family Dental may use the photographs, video, and sound recordings for any safety purposes whatsoever, but NOT for any commercial uses. All rights, titles, and interest in the photographs, video, and sound recordings belong solely to the owner of Omni Family Dental.
I understand and agree to the conditions outlined in this photograph, video, and sound recording release and consent form. I give consent to Omni Family Dental to record my image and voice.
By signing the Financial Agreement, you understand and agree that you are authorized us to check your credit and employment history.