Financial Form

It is your responsibility to provide the front office staff with new or current dental insurance information. If your insurance has changed since your last visit, please call, or email the office to provide them with updated information. Failure to do so in a timely manner may result in you paying for the services out of pocket. It is your responsibility to know your benefits, frequencies, and limitations. If there are any services you do not want your child to receive, please notify the front office prior to your child’s appointment. Fluoride treatments and x-rays are recommended and will be performed at each routine visit unless otherwise requested. If your child is scheduled for routine or preventative care at our office, we will send that claim to your insurance company. If your insurance company does not cover all the services your child receives or if they deny the claim for any reason and no payment is issued, you are responsible for that balance 30 days after the appointment. If the balance has not been paid within 60 days, a repeat billing charge will be applied to your account each month until a payment has been made or the balance has been paid in full. If you have an unpaid balance, you will receive a statement in the mail monthly until the balance is paid. You can pay your balance via mail, phone call, or at kidsfunsmiles.com. If you choose to pay online, there is a small convenience fee.

Dental work appointments:

If your child is scheduled for treatment with our office, we will send a predetermination to your insurance company. Most insurance companies will review the predetermination and return an estimate of what they will pay and what the patient will owe for the proposed services. This process may take up to 2-3 weeks. Once our office receives the estimate of what you will owe, we will call you with your patient portion. Your insurance company should also send you a copy of the predetermination as well for you to review. If you have not received an estimate from our office or from your dental insurance company or if you have any additional questions or concerns, please call the office. The patient portion will be due in full on the date of service. If you are unable to pay the amount in full, you can set up a payment plan with the front office.

Cancellations and no shows:

We understand that schedule conflicts, unexpected emergencies, and illnesses occur, and our goal is not to penalize any of our patients for that. However, we do ask for 24-hour notice if you need to cancel an appointment as a courtesy to our staff and other patients. We have a cancellation list, and those families count on having sufficient notice from us of our availability so that their children can receive the care that they need. Therefore, if an appointment is missed and no notice has been provided to us, there will be a $50 charge. Similarly, if you cancel your appointment on the same day that you are scheduled, there will also be a $50 charge. This policy will go into effect January 1st, 2024.

Acknowledgement of Receipt

I acknowledge that I have been provided with a copy of Dr. Stinnett’s Office Policies. I have read and agree to the terms of the Office Policies.

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.