If you have dental insurance, we will be happy to file your claim as a COURTESY. However you will be responsible for your deductible and any coinsurance at time of service. Our dental software estimates what your insurance should cover and what your “out of pocket” portion should be. This is only an estimate and it is possible that your insurance may cover less than what is estimated. If this should happen then the remaining balance will be your responsibility to pay in a timely manner.
Our practice is committed to providing highest quality dental care and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Many think that their insurance pays 100% of dental fees. In reality most plans pay 30% to 80% of the total fee. How much your insurance pays is controlled by your employer, not our office. It is always our intention to do what is best for your child regardless of your insurance coverage. If you have any questions, please discuss them with our office manager. We are dedicated to providing the best possible care and regard your understanding of our financial policies as an essential element of care and treatment.
Toothbud Pediatric Dentistry accepts payment in the forms of cash, check, MasterCard, Visa, Discover and American Express. For all insufficient fund checks our office fee is $35.00 per transaction.
I authorize Toothbud Pediatric Dentistry to release to insurance companies, or their representatives, information and records about my child/children about services rendered that is needed to review, investigate or evaluate any claim for benefits. If my coverage is under a group master agreement held by my employer, an association, trust fund, union or a similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit.
We will consider an account delinquent when the balance goes unpaid in 90 days without a financial arrangement. Delinquent accounts will be turned over to an outside collections agency for handling. The parent/ legal guardian will be responsible for all costs associated with this process. Families who have had their accounts turned over to collections will no longer be considered active in the dental practice and may only be seen on a cash basis once the balance has been taken care of with the collection agency.
I, the legal guardian hereby give my authorization to Dr. Ann Dimick and team members of Toothbud Pediatric Dentistry to render dental treatment to my child (children) that they judge to be beneficial to their oral and overall health. In giving this authorization it is understood that my child’s dental needs will be explained to me and the options for the treatment of said dental conditions will be explained with the pros and cons of each treatment option. It is understood that I have the right to refuse any treatment options presented. However with refusal of treatment it is also understood that Dr. Dimick has the option to refuse future treatment and even dismiss our family from the practice when such refusal of treatment is seen as detrimental to my child’s health, or compromises the dentist’s professional ethics.
Dr. Dimick is available for dental emergencies to confirm the patient is stable and can be seen for care when the practice has all team members present to give best comprehensive quality care. If you have an after hour emergency please call the office and leave a message, all messages are recorded and sent as an email to Dr. Dimick. She can hear the message and respond.
Courtesy reminders may be provided as requested via text, email, or both. We request that you give us 24 hours notice if you need to cancel or reschedule an appointment; however if an appointment is missed without a 24 hours notice it is understood that the practice has the right to charge $35.00 non-refundable fee per child for non-treatment appointments; and $75.00 nonrefundable fee per child for treatment appointments.
If the family arrives 15 minutes late for a scheduled appointment you may be asked to reschedule, or shorted treatment planned. This is done out of respect for our other patients that have appointments scheduled. We would ask that you call ahead and let us know if you are running late so that we can try to accommodate you as our schedule permits.
Use of cell phones in the treatment rooms is prohibited and they must remain off during your time in the back office.
Texas State Law requires that we obtain your written informed consent for any treatment given your child as a legal minor. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain more.It is the policy of Toothbud Pediatric Dentistry to inform parents of all procedures contemplated for your child. At each examination appointment, we will identify any dental treatment needed and describe this to you and your child. Each check-up visit consists of oral hygiene instructions, cleaning of the teeth, as needed topicalapplication of fluoride, as needed radiographs/x-rays, examination of the mouth and the bite. Any other treatment recommendations such as fillings, crowns, extractions, etc. will be performed after obtaining your permission and most likely at a separate appointment.I hereby authorize Dr. Ann Dimick assisted by members of her dental practice to perform upon my child, the following records as needed which may include photographs, radiographs, other diagnostic materials and treatment for the purpose of diagnosis and treatment.I authorize Dr Dimick to use in general terms the dental procedures with consent prior to performing such dental treatment such as behavior management, nitrous oxide, fillings, crowns, extractions, nerve treatment, spacer appliances, sealants and other such dental treatments after a detailed treatment plan is presented for proper informed consent.I fully understand there is a possibility of surgical and /or medical complications developing during or after the procedure. These risks and side effects may cause necessary hospitalization, further surgical procedures, disabilities, nerve damage, brain damage, or death. I further authorize the doctor to perform treatment as may beadvisable to preserve the health and life of my child.I hereby state that I have read and understand this consent and that all questions about the procedure(s) have been answered in a satisfactory manner. I understand that I have a right to be provided with answers to questions, which may arise during the course of my child’s treatment. This consent will remain in effect until such time that I choose to terminate it.
I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes.
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.
Click a signature you want to use: