APPOINTMENT CANCELLATION INFORMATION
A broken appointment is a loss to everyone. Remember, once you have made an appointment, this time is reserved for you. Please give us at least 48 hours notice if you are unable to keep your appointment. This will allow us to accommodate the needs of other patients more readily. If we do not receive a cancellation notice within 48 hours, a cancellation fee of $25 per half-hour of scheduled time will be applied to your account.
You are responsible for all charges incurred on your account.
• We are pleased that many of you have dental benefits and our office will assist you in obtaining the maximum benefits specified in your contract. However, your benefits are a contract between you, your employer, and a carrier. We will assist you in determining your benefits as best we can. Because plans differ from carrier to carrier and policy to policy, our office may refer you to your carrier or your employer’s benefits coordinator for assistance in understanding your plan.
• As a courtesy to you, we will file your benefits claim and accept assignment of benefits. We ask that your estimated co-payments and deductible be paid at the time of service.
• Balances with benefit claims outstanding more than 60 days may be reverted back to the patient.
• Not all services are a covered benefit in all contracts. Some carriers and employers select only some services to be covered. You are responsible for payment of all services regardless of the payable benefit.
Any estimated amounts due and payable by the patient (including co-pays and deductibles) are required to be paid on or by the day the services are performed.
Methods of Payment
1.) Dental Benefits
2.) Cash, Check, MasterCard, Visa, American Express and Discover Card
3.) Springstone Plan(Third Party Financing) and CareCredit
• Balances older than 60 days may be subject to additional fees and interest of 1.0% per month, or 12% annually. These additional fees will be applied to the unpaid balance at the end of the second month.
• In the event that your account is not paid and we refer the account to collection, you will be responsible for all fees incurred for collection of your bill (i.e., attorney fees, court costs and collection agency fees).
AUTHORIZATION TO RELEASE INFORMATION AND ACCEPT ASSIGNMENT OF BENEFITS
I agree to be responsible for all charges for dental services and materials not paid by my dental plan, unless prohibited by law, or unless David A. Knopf, DDS, PLLC, doing business as, Abella Dental, has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to the use and disclosure of my protected health information (PHI) to carry out payment activities in connection with any and all claims. I understand and authorize that this authorization remains in effect provided that I am a patient of record with David A. Knopf, DDS, PLLC, doing business as, Abella Dental.
REGARDING TREATMENT PLANS AND INSURANCE
The fees presented in your treatment plan are those that have been decided upon by a contract between your plan sponsor (typically your employer) and your benefits (insurance) carrier or by your benefits carrier on behalf of your plan sponsor. These fees have been or will be supplied to us by your carrier. The fees presented in your treatment plan are the best estimates based on the latest information available from your carrier. Those fees are estimates, final charges will be determined when the claim is adjudicated (paid) by your insurance carrier. When billed, our usual and customary fees will be submitted to your carrier. You may ask us for Abella Dental’s usual charge for any procedure(s) listed here. Any estimated amounts due and payable by the patient (including co-pays and deductibles) are required to be paid on or by the day the services are performed. You are responsible for all charges made to your account.
NOTICE OF PRIVACY PRACTICES
David A. Knopf, D.D.S., P.L.L.C., doing business as, Abella Dental, keeps a record of the dental care services that are provided to you. Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed and how you can access that information. Abella Dental will not disclose your record to others (except in the circumstances described in our Notice of Privacy Practices) unless you direct us to do so, unless the law authorizes us to do so, or unless circumstances compel us to do so. You may ask to see a copy of your record or get more information about it by contacting: Abella Dental, Custodian of Records, Privacy Officer, 300 110th Avenue Northeast, Suite 1-01, Bellevue, WA 98004