Forms & Office Policies

Please download the following form and complete before your first visit

New Patient Forms

Do I Stay with My Child During the Visit?

Yes, Dr. Michael encourages the parents to stay with your child. However, there are some instances where the child will do better when you stay in the waiting area. Dr. Michael or the staff will inform you of these times.

How are Appointments Scheduled?

The office attempts to schedule appointments at your convenience and when time is available.  Preschool children should be seen in the morning, because they are fresher and we can work more slowly with the child for their comfort.  School children with a lot of work scheduled should be seen in the morning for the same reason.  Dental appointments are an excused absence.  Missing school can be kept to a minimum when regular dental care is continued.

Since appointed times are reserved exclusively for each patient, we ask that you please notify our office 48 hours in advance of your scheduled appointment time if you are unable to keep your appointment. Missed appointments without 24-hour notification are considered “NO SHOW” appointments and will result in a $25.00 fee. This fee must be paid prior to being scheduled again.

What about Finances?

Payment for professional services is due for each patient at the time of services.  Every effort will be made to provide a treatment plan which fits your timetable and budget, and gives your child the best possible care.  We accept Cash, Visa, MasterCard, Discover, and American Express.

Our Office Policy Regarding Dental Insurance 
If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you.  You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay.  By law your insurance company is required to pay each claim within 30 days of receipt.  We file all insurance electronically so your insurance company will receive each claim within days of the treatment.  You are responsible for any balance of your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 60 days a rebilling fee of 1.5% will be added to your account each month until paid.  We will be glad to send a refund to you if your insurance pays us.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients.  We do not have a contract with your insurance company, only you do.  We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim.  We can only assist you in ESTIMATING your portion of the cost of treatment; we at no time guarantee what your insurance will or will not do with each claim.  We also cannot be responsible for any errors in filing your insurance; once again we file claims as a courtesy to you!

Dental insurance is meant to be an aid in receiving dental care.  Many patients think that their insurance pays 90% – 100% of all dental fees.  THIS IS NOT TRUE!  Most plans only pay between 50% – 80% of the average total fee.  Some pay more, some pay less.  The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee.  Frequently, insurance companies state that the reimbursement was reduced because your dentists’ fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company.

A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentist in the area charge for a certain service.  This can be very misleading and simply is not accurate.

Insurance companies set their own schedules and each company uses a different set of fees they consider allowable.  These allowable fees may vary widely because each company collects fee information from claims it processes.  The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee.  Frequently, this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20% – 30% profit.

Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low.  In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.

When estimating dental benefits, deductibles and percentages must be considered.  To illustrate, assume the fee for service is $150.00.  Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid.  First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure.  The insurance company will then pay 80% of $100.00, or $80.00.  Out of the $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient).  Of course, it the UCR is less than $150.00 or your plan pays only 50% then the insurance benefits will also be significantly less.

MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company, address, or a change of employment.