Financial Policy

Insurance Benefit Disclaimer

At MV Kids Dentists and Braces, we are dedicated to the helping you maximize the insurance benefits for your child. It is imperative that all financial arrangements be clearly discussed and fully understood.

Please be advised that we are a third party, we are not in contract with any insurance, and we are not your insurance policy holders. When you present to us your insurance information, we will try our best to verify your insurance information as accurately as possible, based on the information we receive from the particular insurance representative at the time of the phone conversation, and/or the information available on the insurance website at the time of the insurance verification. Please be mindful that we are not responsible for any change and modification to your insurance coverage that may occur at any time apart from the time of our insurance verification. We are also not to be held responsible for any incorrect information presented by your insurance representative. We cannot guarantee coverage due to the complexity of insurance contracts. We will prepare and file claims to you as a courtesy.

Assignment of Benefits

I understand that my signature below indicates my acceptance of all the information presented on this page. I also understand that my signature below serves as a “signature on file” to bill the insurance company I have provided information for and allows MV Kids Dentists & Braces to accept assignment of insurance benefits.

Co-Payments

As a pediatric-orthodontic specialist office, we have our own UCR (Usual, Customary and Reasonable) fees for all dental services offered in the office. As we are not a contracted insurance entity, our fee is not necessarily the same as your insurance accepted fee. There may be an out of pocket fee for the difference between your insurance accepted fees and our UCR fees. Your estimated patient portion must be paid at the time of service. We accept payment through Visa, MasterCard, American Express, check, and cash payments. Any payment received from your insurance plan will be credited towards your account. Although we make every effort to collect payment from your insurance, we are not responsible for how your insurance company handles its claims or for what benefits they choose to pay on each claim. If, after 60 days after the date of your service, your insurance has not submitted payment to our office, you are responsible for the entire balance, paid-in-full. At that point you are encouraged to pursue the payment from your insurance company.

Fee associated to broken appointments

We require a minimum of 2 business day notice for any rescheduling. While we understand that sometimes situations are outside of your control, we strive to show courtesy to all our patient families, including those who are on a waiting list for your appointment time. Our fees for the notice less than 2 business days are as followed. Please note that this fee is applied per an appointment time slot, and not per family. For example, for a broken appointment of two children on a Saturday, you will be responsible for $75 x 2 = $150.

• $50 fee for a recall appointment

• $75 fee for a Saturday appointment

• $150 fee for a broken treatment appointment, and a deposit will be required to schedule future treatment.

• For hospital surgery and in-office general anesthesia appointments, broken appointment charges will be assessed at the doctor’s hourly rate and may include a rescheduling fee.
  
  

Past Due Accounts

If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay a $100 processing fee, as well as all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all attorneys’ fees which we incur plus all court costs. You agree to grant permission for us to telephone you to discuss matters related to this financial policy or financial arrangements. You agree that charges incurred for services rendered shall be billed at the time of service. Any objection shall be made in writing prior to the start of patient care. You understand that if you default on payment, information to assist in collection of this account may be given to an attorney, collection agency, or professional contracted by the office.

Waiver of Confidentiality

You understand that if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you or your child receive treatment at our office may become a matter of public record.

Divorce

In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. Should the parent holding the insurance for the child be the party NOT authorizing treatment, the parent authorizing treatment must provide sufficient contact information for the insured parent.

NSF Charge

Fifty US dollars ($50) will be charged if a personal check is returned as "insufficient funds" and a different form of payment will be expected for past balances and future services rendered.

Insurance FAQ Patient Forms