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OFFICE POLICIES
Minou Chau, D.D.S.
Our philosophy is to provide you the highest quality of patient education and dental care to all of our patients. To ensure that you begin with a positive experience we have prepared the following information for you to review. Please feel free to let us know if you have any question or concerns.
EXPECTED PAYMENT
In order to keep our fees as low as possible, we ask that payment be made at the time of service. For your convenience we will provide you an estimate for services in advance of your appointment/s to ensure you opportunity to plan in advance for your dental care. We believe whether you privately pay or have dental insurance to assist you, everyone deserves the care they need and want.
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DENTAL INSURANCE
We are happy to file your claims to assist you in receiving the full benefits of your coverage. We ask that you familiarize yourself with your insurance benefits, and provide us the correct information for the submittal of your claims. We will accept the estimated insurance payment directly from your insurance company provided payment is received from them within 60 days. Please remember that your insurance is a contract between you, your employer, and the insurance company; therefore, you are ultimately responsible for the total amount of your dental fees. The treatment recommended for you is indicated regardless of your dental insurance benefits, deductibles, limitations, or maximums.
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PAYMENT OPTIONS
For your convenience we provide a variety of payment options to help you receive the quality care you need to enjoy a healthy and confident smile. Please identify which form of payment is most convenient for you at the time of service.
Cash or Check______ Visa/MasterCard______ Extended Payment Options______(Please see below)
Should you desire a monthly payment plan, we invite you to complete a simple finance company application. There are no application fees or a down payment and the loan can be interest free. Approval is provided to you quickly.
PAST DUE BALANCES
Any Balance owing from a prior visit where insurance is not pending, or an insurance payment has not been received within 60 days, or the account has been sent to collections is considered past due. Payment of any past due balance is requires to be paid in full before incurring any new charges. All balances over 60 days are subject to a $10.00 rebilling fee.
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CANCELLATIONS
If you are unable to keep an appointment that has been reserved for you, we request that you provide us with a 24-48 hour courtesy notice. The earlier you notify us ensures that we can offer you a more convenient appointment and it allows us more time to invite another patient in for care they need, by filling the open appointment time you were unable to keep. We realize that emergencies do occur and we will be flexible under those circumstances. A missed appointment fee of $50.00 will be charged for missed appointments without advanced notice.
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CELL PHONES
We ask that cell phones and pagers be turned off at all times while in the treatment area. If being available for an emergency during your reserved appointment is necessary, please leave our office telephone number so you can be reached. Should an unfortunate emergency arise we would be happy to notify you in the treatment area immediately.
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INFORMATION CHANGES
To ensure our records are current, please notify us of any changes related to your medical history, telephone number/s, address, employer or insurance as they occur.
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My signature indicates that I understand that the policies as outlined and any questions I have with regard to office policies have been answered.
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Signature of Responsible Party or Patient Date
My signature indicates that I have reviewed the office policies with the responsible party and/or patient.
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Signature of Staff Member or Doctor Date
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