We feel our office provides a high quality of service to each patient. Also, we appreciate the consideration you must give to the cost of your dental care. To understand your financial obligation to this office, the following policy has been formed.
1. If you do not have valid dental insurance, the fees for your initial visit and procedures on your treatment plan will be paid on the day each service is provided. For patients with valid dental insurance, a 20% co-pay will be collected at the time of service. After your insurance has paid, statements will be mailed as needed.
2. As a courtesy to you, our office will prepare all forms necessary to process your insurance claims. The doctor can in no way alter insurance claims nor guarantee payment from your insurance company.
3. Any overpayment to us by you or your insurance company will be promptly refunded by mail.
4. If your insurance company does not assign benefits to the doctor for your service, you must pay your initial visit and treatment plan at the time of the service.
5. By my signature below, I acknowledge that I have read and understand this financial policy.
6. I here authorize payment of benefits directly to Dr. Sireesha Boganatham
We truly appreciate your consideration choosing us for your dental care. Our office reserves time for your services, by giving us early notice, we can offer to other patients who are in need. Thus, we have the following cancellation policy. PLEASE READ BEFORE YOU SIGN.
“WE REQUIRE 24 HOURS NOTICE BY CALLING OUR OFFICE (785-272-9443) FOR THE CANCELLATION OF SCHEDULED SERVICES. CANCELLATIONS WITH LESS THAN 24 HRS OF YOUR SCHEDULED APPOINTMENT WILL BE CHARGED ($25 Cancellation fees).
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.