Financial Policy & HIPAA Consent Form | Kids Dental Experts

Financial Policy & HIPAA Consent Form

Please list all children that are seen at Kids Dental Experts®:


Charges not anticipated to be covered by insurance are collected at the time of service. The amount we collect is an estimated patient portion and you may be responsible for an additional balance after the claim is processed. If your dental plan reimburses you directly, our office will collect in full for all services rendered. Filing claims to your insurance(s) is a courtesy. You are responsible for being familiar with your benefits including, but not limited to, deductibles, maximums, co-insurance, and frequency/age/tooth limits. Any attempt by us to provide this information is not a guarantee of payment, and you are financially responsible for any amount the plan does not pay.

Missed Appointments

Short notice changes to our schedule negatively impact the patient care we are able to provide. Please provide 48 hours’ notice when rescheduling appointments. Not doing so will be considered a missed appointment. A fee of $55.00 will be charged for any missed re-care appointment and $105 for restorative appointments. Insurances do not cover this charge and it must be paid prior to scheduling future appointments or transferring records.


We accept cash, check, money order, CareCredit, and debit/credit through MasterCard, VISA, Discover, and American Express. A courtesy discount of 5% will be granted to those who have no outstanding balance and are paying in full with cash or paper check for that day’s services. We offer the option of storing your credit or debit card information on file so that any remaining balances after insurance pays can be processed automatically. Any balance not paid within 45 days of the DOS will be subject to collection proceedings. A $25.00 service fee will be charged to your account if a check is written with insufficient funds.

Responsible Party

Parents are responsible for their children’s account balances. Any arrangements made through a divorce are strictly between the parents and do not involve our office. If the patient portion is not pre-paid prior to a visit, the parent bringing the child to the visit will be responsible for paying the full amount due. When children turn 18 years of age, parents will be given the option to continue to be responsible for that child’s expenses or have them assume responsibility of their own account.

Privacy Practices

Health care operations that are related to dental treatment and processing of claims through insurance may involve the disclosure of your child’s records. You have been offered the form titled NOTICE OF PRIVACY PRACTICES to keep for your records.
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