Any/all account balances over 90 days are subject to a $35.00 late fee.
Accounts where payment arrangements are in default are subject to a $35.00 fee.
A $35.00 charge will be billed to accounts for any returned checks by the bank for any reason.
If sent to Collections due to non-payment, you agree to pay any/all related legal fees and court costs.
DENTAL INSURANCE:
As a courtesy to you, we will process all of your dental insurance claims and do all that we can to help you maximize your insurance benefits. We will provide you with an estimate regarding reimbursement, but cannot guarantee coverage for recommended or provided procedures due to the complexities of insurance contracts. Insurance coverage is subject, but not limited to, plan limitations, exclusions, waiting periods, frequency restrictions, age restrictions, deductibles and maximums. These are parameters within your plan, out of our control, and ultimately between you and your insurance company. Please contact your insurance company for a detailed breakdown of your benefits.
Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible, however, your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.
- All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.
- Our practice is committed to providing the best treatment for our patients and our fees are considered usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
- We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form allows us to release your treatment information to your insurance company and instructs your insurance company to make payment directly to our office (when indicated/applicable). By signing this Financial Policy, you authorize the release of any information concerning you (or your child’s) health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
- When indicated, we ask that you pay any deductible, co-payment and co-insurance, which is the estimated amount not covered by your insurance company, by cash, check, MasterCard, Visa, Discover, American Express or 3rd party financing (ie. CareCredit) at the time we provide service to you.
- Insurance payments are ordinarily received within 30-60 days from the time of filing a claim. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount.
- We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.
Please ask any one of our courteous and knowledgeable team members about our various payment options. We will try to help with any insurance questions, but questions regarding your insurance benefits should be directed to your insurance carrier.
EMERGENCY PATIENTS:
Emergency patients, new to our practice, are expected to make payment at the time service is provided.
MINORS ACCOMPANIED BY A PARENT OR LEGAL GUARDIAN:
The parent or legal guardian accompanying a minor, who has consented to treatment, is responsible for full payment at time of service.
***Unaccompanied Minors: The parent or legal guardian is responsible for full payment at time of service. Treatment consents and payment arrangements with the parent or legal guardian must be made prior to appointment or nonemergency treatment may be denied.
COMMUNICATIONS WITH YOU:
By signing below, you are authorizing us to call you at any number you provide including calls to mobile/cellular or similar devices for any lawful purpose. You agree to any fees or charges that you may incur for an incoming call from us, and/or outgoing calls to us, to or from any such number, without reimbursement from us. We, or our agents, may call by telephone regarding your account. You agree that we may place such calls using an automatic dialing/announcing device. You agree that we may make such calls to a mobile telephone or other similar device. You agree that we may, for training purposes or to evaluate the quality of our service, listen to and record phone conversations you have with us.
CONSENT:
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Informed Consent for Dental Procedures
You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedures, alternative treatments, or the option and risks of no treatment.
It is very important that you provide your dentist with accurate medical and situational information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.
If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.
Please do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered to your satisfaction. By consenting to treatment, you acknowledge your willingness to accept known risks and complications, no matter how slight the probability of occurrence.
CONSENT:
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Informed Consent/Authorization for
Use and Disclosure of Patient Name, Photographs, Voice, and/or Video Images
We pride ourselves on being a fun, friendly, and dynamic office. We frequently take pictures and videos and post to our website as well as to social media sites, such as Facebook and Instagram, to show off the services we provide and the results we get. Thank you for choosing Cornerstone Dental of Henrietta, PLLC for all your oral health care needs and for agreeing to help us!
Authorization:
Before & After Photos:
Research, Training,
Lectures, or Case Studies:
Promotions / Marketing
(Website, Facebook, Instagram,
Brochures, Contests, etc.):
Purpose:
The photographic or video images, voice recordings, testimonials or biographic information may be used in any of the following manners: Internet websites, social media, print, digital, television or internet for advertising or marketing.
Revocability:
No Treatment Conditions:
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ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Cornerstone Dental of Henrietta, PLLC’s Notice of Privacy Practices provides information about how protected health information (PHI) about me (the patient) may be used or disclosed. I have been offered an opportunity to review the Notice, object to the use or disclosure of my PHI, and/or request restrictions as to how my PHI may be used or disclosed for treatment, payment, or healthcare operations before signing this consent. Cornerstone Dental, LLP is not required to agree to any restrictions, but if they agree, will be bound by the agreement. I understand that the terms of the Notice may change and I may obtain a revised copy by contacting the office at (585) 865-7030 or by visiting the office’s website at www.cornerstonedentalny.com.
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FOR OFFICE USE ONLY
Attempts were made to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but could not be obtained because:
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