Terms and Conditions

OFFICE POLICIES

Updated Records:

It is your responsibility to inform Fairview Dental of any changes to your insurance, telephone numbers, and address. Please have your insurance card available at all office visits. Patients will be required to fill out forms every year or as requested.

Authorization for Treatment:

By signing below, you hereby consent to all medical and surgical procedures for the evaluation and treatment of the conditions for which you present yourself to this office. This may include but is not limited to the use of local anesthetic, radiographs, photos, and study models to complete diagnosis and treatment as indicated. In addition, your cases may be discussed with referring doctors and information and radiographs shared. You acknowledge that you are legally responsible for all charges in connection with the care and treatment administered by Fairview Dental and promise to pay whatever charges in return for the medical care and services provided to you in accordance with the terms stated herein. You understand that this consent will remain valid and in effect as long as you receive care at Fairview Dental. This authorization will remain valid and in effect until revoked in writing.

Assignment of Benefits:

By signing below, you hereby appoint as your authorized representative, and assign to, Fairview Dental all of your right, title, and interest in and to, and relating in and to the recovery of, any and all health care and/or surgical benefits otherwise payable to you or to which you are entitled for treatment rendered by Fairview Dental. You also authorize Fairview Dental, on your behalf, to file and prosecute any required appeal, grievance, litigation or arbitration with your health plan for payment of claims and to exert or receive any other rights or benefits under your health plan with respect to the treatment rendered by Fairview Dental. You further authorize Fairview Dental to release to your health plan, or its agents, any information about you needed to determine the benefits payable for treatment rendered by Fairview Dental. You certify that the information given by you to Fairview Dental in applying for insurance coverage or other protection is correct and complete. This assignment will remain valid and in effect until revoked in writing.

Appointments:

If you are having an emergency, please dial 911 immediately. Appointments can be made by calling during office hours. If you are unable to keep your appointment, please reschedule at least one day prior to your original appointment. If you fail to appear for an appointment, you may not be immediately rescheduled. If you arrive late for your appointment, you may be rescheduled or worked in depending on our schedule. By signing below, you understand that the team may call, text, and email regarding upcoming appointments and other correspondence.

Financial Policy:

Payment for services is due, in full, at the time Fairview Dental renders service. You acknowledge full responsibility for the payment of services.

You understand that your insurance coverage is an agreement between you and your insurer. You understand that Fairview Dental is not a participating provider with any dental insurance. It is your responsibility to remit payment for charges not covered by your insurance or for any remaining balance that your insurance company states is your responsibility, according to the terms of your plan. Please contact your insurance company for clarification of benefits, as they do not always provide that information to our office. Our charges are an estimate of each insurance company’s fee schedule, and you will be asked to pay this estimated amount. Payment for all copays and deductibles are due at the time of your appointment.

Secondary Insurance: Having more than one insurance policy does not necessarily mean that your services are covered at 100%. You are responsible for any balance after your insurance companies have processed your claim. Please advise which plan is primary and which is secondary to assist with your claim processing.

Outstanding Payment: For outstanding balances, monthly statements are mailed to the address provided to our office and are to be paid by you in full within 30 days of receipt. Should your account be turned over for collections or processing, you will be responsible for the account balance and fees incurred to collect payment. We may bill your insurance company as a courtesy, but you are ultimately responsible for payment should your insurance fail to pay within 90 days.

There is a $50.00 charge for all returned or canceled checks. Interest charges will accrue if the balance goes beyond 90 days.

Consent:

By signing below, I fully understand the Office Policies of Fairview Dental and agree with all terms stated herein. I also understand and agree that the terms of this Office Policies may be amended by Fairview Dental at any time without prior notice to me. A photocopy or electronic version of this Office Policies is considered as valid as the original.