Office Policy Acknowledgement Form

1. Payments: Payments/Copayments are due on day of service. Payment options are cash, debit card, or credit card (VISA, MasterCard, or Discover, CareCredit). For larger treatments and procedures, financial arrangements must be made with our finance department prior to the start of any procedure.

2. Dental Insurance: Insurance is a contract between you and your insurance. There is no direct relationship between Happy Teeth Dental Care, PC and your insurance company. Benefits are determined by the plan selected by you and/or your employer and we are not a party to this contract. The terms of your contract, methods of reimbursement, and determination of your benefits are defined by your insurance company and not Happy Teeth Dental Care, PC. We will file your dental insurance claims as a courtesy to you. We do not guarantee payments and are not responsible for providing you with the plan limitations, exclusions, and provisions determined by your insurance company. You agree to pay your portion of the charges not covered by your insurance.

3. Cancellation/Broken Appointment Fee: 48 hour notice of cancellation is required for all major procedures (ie. CEREC, root canal, dentures). A $50.00 per half hour broken appointment fee will be applied to your account. 24 hour notice of cancellation is required for all other procedures (ie. cleaning, filling, follow up). A $50 broken appointment fee will be applied to the account. A new appointment cannot be made until all fees are paid.

 

4. Dental Practice Transfer: Patients who are looking to transfer dental records to another dental practice are required to complete a dental release form or confirm all necessary information to obtain private dental records. Please note a processing fee of $15.00 may be assessed to obtain radiographic images.

 

5. For MassHealth Members: MassHealth members with dual dental insurance are responsible for paying any remaining co-pay or service not covered by MassHealth. Broken appointments will be reported per MassHealth request.

 

6. Emergency/After Hours Appointment: Patients who are seen for an emergency visit after our regular business hours, an “after hour” fee is charged in addition to any treatment on that visit. All emergency treatment must be paid in full at the time of service.

 

7. Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show the previous balance, any new charges made to the account, finance charges (if applicable), and any payment or credit applied to your account during the month. Professional fees are the responsibility of the parent or guardian authorizing treatment. We cannot send statements to other persons.

 

8. Past Due Accounts: A finance charge of $5.00 will be added to your account for any balance that remains unpaid after 30 days after receipt of notice. This charge will be assessed monthly, until the remaining balance is paid in full. If your account is past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay the collections costs which are incurred.

9. Divorce: In case of divorce or separation, the parent/guardian bringing the patient to the office is financially responsible. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the parent/guardian.

 

10. Effective Date: Once you sign this agreement, you agree to all terms and conditions herein and the agreement will be in full force and effect.

This agreement is between your treating dentist; Dr. Nguyen M. Tau, Dr. Nguyet M. Tau, or Dr. Phil Chung, and the patient/parent/debtor named on this form.

 

In this agreement, the words “you”, “your”, and “yours” means the patient/debtor. The word “account”, means the account that has been established in the patient’s name to which charges are made and payments are credited. The word “we”, “us” and “ours” refers to your treating dentist; Dr. Nguyen M. Tau, Dr. Nguyet M. Tau, or Dr. Phil Chung at Happy Teeth Dental Care, PC.

By executing this agreement, you agree to the terms of the financial agreement and agree to pay for all services that are received.

Patient/Responsible Party Signature

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© 2020 Happy Teeth Dental Care, PC

Happy Teeth Dental Care

135 Boston Turnpike 

Shrewsbury, MA 01545

Office Phone Number: (508) 425-3316

Office Fax Number: (508) 753-3318