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We believe that you deserve the best care. Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and comfortable as much as possible throughout our relationship. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits but some don’t. If you have dental benefit, congratulations! Here are some important things you should know…

Your dental benefits are based upon a contract made between your employer and your insurance company.

As a courtesy to our insured patients, we submit claims to your insurance company free of charge. We will help you to receive your maximum allowable benefits. In order to do this we need your insurance card and/or insurance policy with you on your first visit of every calendar year (your insurance year may not run January – December)

Our doctor will diagnose treatment based on your dental health not your insurance coverage!

You must realize that: Our office is not, and cannot be a part of that legal contract. Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit, typically provided by an employer, to help their employees pay for routine dental services. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost of a person’s necessary dental treatment.

If your insurance has not paid within 90 days of services rendered. You will need to make full payment to Vega Smile Studio. And you will be reimbursed when your insurance company pays. After 90 days the patient is responsible to pursue payment from the insurance company. Ultimately, you are responsible for ALL charges incurred in our office. If your insurance company does pay us subsequent to your appeal, Vega Smile Studio will reimbursed any credit on your account. All current documentation will be provided by email or mail in order to assist your inquiries.

Patients are expected to pay for all services at the time they are rendered. Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service. Payments may be made using cash, check, Visa, MasterCard and/or Discover. We also offer CARECREDIT which is financing options that are available only for healthcare expenses. We will mail monthly statements to all patients with an outstanding balance after 90 days.

In order to serve you better we try to maintain an efficient appointment system. However, our cost of providing care increases greatly when people fail to keep scheduled appointments or cancel at the last minute. We strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hour notice to avoid a $50.00/hr. cancellation fee. (Emergencies are an exception).

Please indicate your understanding and acceptance of these insurance and financial policies by signing below.

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
• A basis for planning my care and treatment
• A means of communication among the many health
professionals who contribute to my care
• A source of information for applying my diagnosis and surgical information to my bill
• A means by which a third-party payer can verify that services billed were actually provided
• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

If the individual or parent/legal guardian did not sign above, staff must document when and how the Notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.