Office Financial Policy

Financial Policy

Thank you for selecting our office for your child’s dental care. We are committed to providing the
best quality of dental care and the best service possible. The following is a statement of our Financial Policy. We ask that you read and sign it prior to any treatment.

Full Payment is due at the time of service.
We accept cash, personal checks, and for your convenience Visa, MasterCard, Discover, and American Express. Dental Insurance:
Currently, we participate with a limited number of insurance plans. Please note that your
insurance contract is between you, your employer, and your insurance company. We are NOT a party to that contract.

1. If we participate with your primary insurance, as a courtesy, we will gladly process your
claim for you. We require, however, that you pay your ESTIMATED portion when services are
rendered. Any amount for procedures not covered by insurance, or the difference in the estimated portion is the patient’s responsibility. Our office will file your insurance a maximum of two times per appointment.

2. We only accept PRIMARY insurance. If your dental insurance is a SECONDARY policy, we will be unable to process your claim and you will be responsible for full payment at the time of service.
We will, for your convenience, provide you with a completed claim form to submit to your insurance company.

3. If the claim is not paid by your insurance carrier within sixty days, you will be responsible
for the full balance and further insurance appeals become your responsibility.

4. You must provide the office with either a dental insurance card with the proper policy
number and mailing address of the insurance company, or a dental claim form provided by your employer. If none of these documents are available at the time of the appointment, you will be responsible for payment of all fees. We will provide you with a claim form for you to submit for reimbursement.

5. If we do not accept your insurance, as a courtesy, we will be happy to provide you with a
completed claim form to submit to your insurance company. *Do not sign the authorization to pay directly to our office.*

Appointment Information:

If you cannot keep your scheduled appointment, we ask for at least 24 hours notice. A $50.00 fee
will be charged for a sec- ond failed appointment. Multiple failed appointments will result in
discharge from our care.

Past Due Accounts:
All fees are due at the time of service. Should this matter be turned over to collections, all
costs, including reasonable collections fees, attorney fees, and court cost incurred by Alan K. Kuwabara, D.D.S., PLLC shall be borne
by the undersigned.

I have read, understand, and agree to this Financial Policy.