Your Rights

Understanding Charges

You have the right to know the immediate and long-term financial implications of treatment choices, as far as they are known, and you have the right to receive within a reasonable period, an explanation of the clinic’s statement of charges for services rendered. Upon request you will be provided with an itemized statement to assist in completing and processing your insurance forms.

Your Right to Confidentiality

You have the right to confidentiality in the handling of your health information except when reporting is required by law. You have the right to personal privacy as written in the federal regulation, Health Insurance Portability and Accountability Act (HIPAA). We will make reasonable efforts to see that its uses, disclosures, and requests for disclosure of Protected Health Information are limited to the minimum amount necessary to accomplish the billing and collection of your account(s).

Your Responsibilities

Your Responsibility to Provide Complete and Accurate Billing Information

It is important that we are provided with complete health insurance information upon registration. This includes presenting a driver’s license or ID, all insurance cards and authorization forms. This information must be provided each time you are registered.
You are required to provide ALL active insurance policies relevant to the visit at registration. Failure to disclose a policy at registration may result in our office declining consideration of the insurance and the balance will be your responsibility. This includes expiring policies, secondary policies and third-party liability plans (attorney, auto insurance, etc.)
You are responsible for your physician’s order if you are scheduled for outpatient services. If you do not have an order, please be sure your physician has faxed it to the clinic prior to your arrival. Your order must include a diagnosis. You are responsible for providing information relating to your plan coverage at the time of admission or registration. Please understand and comply with the requirements of your insurance. Know your benefits and obtain proper authorization for services when required. The HMO, PPO or Medicaid Managed Care plans may require a referral, prior authorization, or certification prior to services being rendered. If you receive a service that is not covered by your insurance, you may be asked to sign an Advance Beneficiary Notice or Waiver of Non-Coverage to signify that you have been informed of your payment responsibility.

No Show and Same Day Appointments.

Failure to show for a scheduled appointment or a cancellation of the same day may result in a $25 fee. If applied, this amount will be billed to you and will not be billed to your insurance. Payment will be required before we will schedule any future appointment. Circumstances will be taken into consideration on a case-by-case basis before this fee is applied.

Your Financial Responsibility

You have the responsibility to meet your financial obligation to the clinic. That responsibility includes the provision of information necessary for filing insurance claims, and cooperation with the clinic when other payment arrangements are necessary.

• Copays. As established by your insurance, co-payments are required to be paid at each visit. Visits during the defined post-operative period are excluded from this requirement.
• Deductible and Coinsurance. These are determined by your insurance. Depending on the additional services you received during a visit (like x-ray, injections, and/or braces) you may be responsible for unmet deductible and/or coinsurance payments. Where possible, we will make our best efforts to identify these before, but it is you, who is responsible for understanding your insurance benefits.
• For your convenience, we accept cash, personal checks, money orders, Visa, MasterCard or Discover. Short-term interest-free payment options are available as well as loans for the longer-term payment plans.

Please let us know if you anticipate problems paying your bill. If you are having financial difficulties, please let us know. Financial Services at the clinic can discuss payment alternatives that may be available to you.