Life with Braces

Thank you for choosing our office for your orthodontic needs. It is important to be aware of the following office policies before starting treatment Financial Policy When reviewing the financial agreement (contract), please take note that your monthly payment will be automatically deducted from your checking account or processed to your credit card.  Payments will be processed on the first (1st) or fifteenth (15th) of the month.  If funds are not available, a late charge of $15.00 will be assessed. If payment is 30 days delinquent, a 30 day letter will be sent. During this month the patient will be seen but no active treatment will be performed.  We will check for broken or loose appliances and evaluate hygiene until the account is brought current. If the account falls 60 days delinquent, late charges are applied on both late payments.  No active treatment will occur until the account is brought up to date.

New Patient Form   We ask that you fill out and return the Patient Information form. Patient Info (Word Format)

If the account falls 90 days delinquent, further late charges are applied and a DISMISSAL letter will be sent by certified mail.  This will terminate our responsibility to the patient.  Further orthodontic treatment will have to be rendered by another orthodontist. However, if the patient finds alternate financing and pays the entire unpaid balance, active treatment can be reinstated. A monthly payment is simply a convenient way to spread out the cost of orthodontic treatment and is not related to treatment progress or appointments; therefore, payment is still deducted/credited even if there is no appointment during the month. The balance of the total treatment fee is due before the appliances are removed. If you transfer during the course of treatment, your account will be prorated and the account will be settled prior to sending your records to your new orthodontist. Insurance Policy Upon verification and assignment of orthodontic insurance benefit, an insurance ledger will be established with the amount of estimated insurance benefits.  Our office will then be responsible for the monthly/quarterly filing of insurance statements. Insurance will pay provided the patient is still eligible for coverage, active treatment is still being rendered and the lifetime orthodontic benefit has not been exceeded. If for any reason during active treatment the insurance benefits decrease, change or terminate, the unpaid balance will be transferred back into the patient’s ledger and will be the responsibility of the patient. Any unpaid insurance balance at the end of treatment is the patient’s responsibility and must be paid before appliances are scheduled to be removed. It is the patient’s/parents responsibility to inform us of any change in coverage or company. We may need to ask your help in filing out forms or making calls to the insurance company. We reserve the right to refuse to process/accept insurance benefits at any time. Extra Charge Policy Broken appointments without 24 hour advance cancellation notice will be assessed a fee of $25.00 per 15 minutes. Broken appliances which are the result of poor patient cooperation will be assessed a repair fee of $25.00 per broken appliance.  This fee is due at the time of repair. ADDITIONAL MONTHLY CHARGES MAY BE INCURRED FOR EXTENDED TREATMENT TIME DUE TO POOR COOPERATION.  (i.e. lack of rubber band and/or headgear wear, poor tooth brushing and improper diet, and lost time due to breakage or missed appointments). Our services may be discontinued for lack of cooperation. Your financial agreement includes one set of retainers. If you require another set because they are lost, damaged or you had restorative dental work, there will be a charge for the new retainer(s). A $20.00 charge will be made to patient’s account for any returned checks, or non-sufficient funds of automatic check debit and credit cards. Treatment Cooperation Policy Successful treatment is dependent on the following: Patient cooperation in elastic wear Proper oral hygiene Care of appliances: broken or lost treatment time Keeping appointments as scheduled (broken appointments interrupt treatment progress) Eliminating foods and eating habits that break or distort the appliance Reporting broken or lost appliances promptly Appointment Policy Appointments are normally scheduled at six (6) to eight (8) week intervals. In order to provide quality orthodontic care, it is necessary to schedule some appointments during school/work hours. Appointments an hour or longer will be scheduled in the morning.  We understand that this can be inconvenient for some patients.  However, it is important to schedule lengthier appointments during school/work hours to achieve the best possible treatment.  It is up to the patient to schedule his/her own appointments on a timely basis.  These can be scheduled when leaving after each visit and are therefore scheduled in advance.  Twenty-four (24) hour notice is required to cancel an appointment.  If an appointment is missed, it is the patient’s responsibility to contact our office immediately to set up a new appointment. As a courtesy to you, an automated system will confirm your appointment 1-2 days prior to your appointment.  Please do not rely on this as the only means of remembering your appointment as there could be technical circumstances that may prevent a call from going out.  We offer this only as a courtesy to you.  We can also email a reminder to you two days before your appointment.  Please provide us with your email address if you would like to take advantage of this method. Dental Care Policy General dental care and checkups are the responsibility of the patient and your regular family dentist. We advise patients to see their general dentist every three (3) months during active orthodontic treatment. In the event that you have changed dentists or there has been a change in medical history, please notify our office as soon as possible. BACK TO TOP