New Patient Policy Form
"Scheduling and Canceling Appointments"
• We pride ourselves on being on time. We do not want to waste anyone’s time, including yours. To help this effort, we ask that you be on time. We try to be as flexible with our patients as possible when they have special scheduling needs. We must have at least a 24- Hour Notice of Cancellation of an appointment. When you late cancel or fail an appointment it does not give us adequate enough time to fill the time slot and not only do we lose money, a patient who may be in need of a dental appointment is prohibited from receiving treatment.
• EFFECTIVE JANUARY 1ST 2014 IF YOU NO-SHOW OR LATE CANCEL ANY OF YOUR SCHEDULED APPOINTMENTS, A $35 FEE WILL BE APPLIED TO YOUR NEXT APPOINTMENT.
Policy Regarding Children
• If you have an appointment for your child and that child is under the age of 18 years, you must accompany them to the office to give consent of treatment; this is legally necessary for a minor under age. The treatment room’s are compact and efficient, and in order to be able to work in them, our office does not allow for anyone other than the Dr., the assistant and the patient to be in the room. We require the parent to wait in the lobby and the assistant or hygienist will talk to you following the visit. There will be no exceptions.
• If you have small children and are scheduled for an appointment in our office, it is your responsibility to arrange childcare. We do not have the provisions to care for your children while they are in our office.
"EFFECTIVE JANUARY 1ST 2014 IF"
"YOU BRING SMALL CHILDREN WITH YOU TO YOUR SCHEDULED" ""
"APPOINTMENT YOUR APPOINTMENT WILL BE CANCELLED AND A $35"
"FEE WILL BE DUE THAT DAY TO RESCHEDULE."
• If you are divorced, the parent who seeks treatment will be responsible for all account"
"balances in full, regardless of who carries the insurance. We will not send separate billing to the non-custodial parent.
Methods of Payment
• We accept cash, check, MasterCard, Visa, Discover and American Express."
• For those without insurance, you will be expected to pay for services in full at the time of each visit."
• For those of you with insurance, your “Estimated Portion” is due at time of service.
"EFFECTIVE JANUARY 1ST 2014 PATIENT’S PORTION FOR THAT DAY WILL BE DUE AT SIGN IN"
• Payment plans are available, with approved credit, through Care Credit and Citi Health Card. Applications are available in office. The front desk will be happy to assist you with this. We recommend that you determine how you will pay for services before treatment begins.
Our billing agency, First Pacific Corporation, manages the billing of our office. They bill"
the entire balance to you, by statement, until the insurance pays.
• When you come in to our office as a new patient, we contact your insurance company and try to ascertain to the best of our ability, what your benefit coverage will be. We use this information during assessment to generate a “Treatment Estimate”. It is your responsibility to know your policy waiting periods and limitations, exclusions and coverage.
• Your insurance is a contract between you, your employer and the insurance company; not your dental office. While the filing of all insurance claims is a courtesy that we extend to our patients, all charges are your responsibility.
• Dental insurance is to provide basic care for specific dental services. Unfortunately, some of the services that you may want or need will not be covered by your dental insurance. There will be co-pays, deductibles and percentages due, along with services that are not covered. We treat the patient based on the ideal care for their dental health, regardless of insurance benefits.
• We cannot be responsible for services not covered or balances that have not been paid by your insurance. Please familiarize yourself with the “Explanation of Benefits” sent to you from the insurance company after every claim. Know your yearly maximum coverage and keep track of what they have paid.
• EFFECTIVE JANUARY 1ST 2014 IF YOU DID NOT BRING YOUR X-RAYS FROM YOUR PREVIOUS DENTIST WITH YOU, YOU WILL BE RESPONSIBLE FOR THE X-RAYS TAKEN AT YOUR NEW PATIENT APPOINTMENT THAT ARE NOT COVERED BY YOUR INSURANCE.
• Social Security numbers are a necessary part of your financial information with our office. This information as with any of your medical record, is protected with strict confidentiality. You are asking us to extend your credit by filing your insurance for your charges and not collecting in full at the time of service, therefore we must have this information or all charges must be paid at the time of service. A copy of the HIPAA Privacy Act is available upon request at the front desk.
We will do our best to provide accurate and timely information, for the processing of your claims. If at any time you have questions, please feel free to call the office at 417-667-7134.
The office and staff of Dr. Ronald D. Schowengerdt, DDS
"I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information for treatment, payment and health care operations."
"I have read and I understand the above Policies. A copy of the HIPAA Privacy Act has been made available to me."