Insurance: As a courtesy to all patients we will verify your dental insurance benefits, but you are responsible to know your plan coverage, exclusions, and limitations. Furthermore, you should be aware of non-covered benefits such as a missing tooth, clause downgraded limitations for fillings, and downgraded all porcelain crowns to porcelain metal crowns on molar teeth, frequency limits for exams, prophylaxis (normal cleanings), fluoride and x-rays, etc. The estimated amount not covered by your insurance is due at the time of treatment and may be paid by check, cash, or credit cards. We also offer a Care Credit financing program.
All estimates are subject to final approval by your dental insurance plan: therefore, the amount due is subject to change after final explanation of benefits have been paid.
INITIAL PAYMENT FOR DENTAL TREATMENT: Most plans are covered for clinical exam and normal cleaning (prophylaxis); no deductible is due for diagnostic or preventive treatment unless otherwise stated. Periodontal maintenance and deep cleanings are usually not covered at 100% like normal cleanings. There are some plans with co-insurance payment for x-rays and dental exams. Deductible for basic/major services customarily include fillings, crowns, extractions, root canal therapy, and periodontal treatment (including periodontal maintenance & deep cleanings).
Deductibles are usually $50 per individual up to $150 per family annually
$175 for any buildup & crown procedure. Some plans do not allow separate benefits for crowns and build-up. In such a case the patient is responsible for the full cost of the build-up.
RESIN-BASED COMPOSITE RESTORATIONS: (Fillings) Some dental insurance plans do not allow full benefits for composites (white fillings) performed on posterior teeth (back molars). The plan benefit will customarily pay for less expensive treatment -amalgam (silver/mercury based restoration). For the best of our patients, we place only composite (white) fillings. The difference is usually around $15 per filling and the patient is responsible for the difference in cost. Please ask if you need more information about composite (white) fillings.
PULP-CAP TREATMENT: (Medicament to protect the pulp chamber) Most dental plans do not allow additional benefits for pulp-cap treatment (this procedure in which the filling is very deep, close to the center of the tooth. The nearly exposed nerve is covered with a protective medication. The cost of this treatment is around $275 per tooth (depends on your insurance coverage) and the patient is responsible for payment at the time of treatment.
FINANCIAL CHARGES: All return checks are subject to a $25 fee. We reserve the right to apply a $20 rebilling fee and $25 late charges toward overdue financial agreements.
MISSED APPOINTMENTS: Please give us a call in advance if you need to reschedule or cancel your appointment. If you repeatedly miss schedule appointments without giving us a prior notice, you may be discharged from our practice.
TRANSFERRING RECORDS: You will need to request in writing, if you would like us to mail, fax, email, etc. any part of your records with Pope Family Dentistry. We need at least 8 working hours in advance to prepare your record to be transferred.
This is an Agreement between Pope Family Dentistry, as a provider of professional services and creditor, and the patient/ debtor named on this form. By reading and signing this agreement, you are agreeing and accepting this policy in full.
I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION; ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION; I UNDERSTAND AND AGREE TO ALL POLICIES OF POPE FAMILY DENTISTRY.