Patient Service & Treatment Financial Policy

Hello!

Thank you for choosing White Street Smiles as your dental healthcare provider. Our team is committed to providing you the highest quality care, to help you attain optimum oral health.

Following is a statement of our Financial Policy, which is provided to clearly define our office procedures regarding payment for patient dental service and treatment. The financial policy is included with our Adult and Minor Dental Patient Forms, or you may Print the Policy on its own.

We require that you read it, and by signing, agree to its terms prior to any service or treatment at our practice.

Questions? Call 203-743-4670 or, visit 289 White Street Danbury CT 06810.

Sincerely,

Dr Joann Paiva-Borduas DDS
White Street Smiles

Patient payment obligations

Payment obligations are due in full at the time of service unless you have made payment arrangements in advance with our front office staff.

White Street Smiles accepts Cash, American Express, Discover, MasterCard, VISA, CareCredit, and Personal Check with prior approval.

Each month, you will receive a statement which, by law, is DUE AND PAYABLE WITHIN 30 DAYS OF SERVICES RENDERED. If payment is late due to circumstances beyond your control, you MUST call our White Street Smiles office – 203-743-4670 to make special arrangements.

Failure to communicate an overdue account without pending insurance or a financial agreement will result in your account being turned over to a Collection Agency.

The patient is responsible for all fees/costs associated with the Collection procedure and will not be accepted back to our office after an account has gone to the collection agency.

Insurance

You will be required to show a copy of your insurance card at the time of service.

IT IS YOUR RESPONSIBILITY TO PROVIDE US WITH ALL THE REQUIRED INSURANCE INFORMATION.

If we are unable to verify your insurance coverage, you are required to pay for your services when rendered. It is also your responsibility to update us with any changes to your insurance coverage within 5 business days of services rendered.

All insurance companies have different coverage and payment policies. Your insurance policy is a contract between you and your insurance company and you are ultimately responsible for understanding your insurance coverage limitations.

You will be required to pay estimated out-of-pocket expenses and deductibles at the time of services rendered.

Estimates

The out-of-pocket portion due is only an Estimate, and you will be billed for any remaining balance due in 30 days. Please be aware that some, and perhaps all of the services provided, may be non-covered services through your insurance policy.

Minor patients (17 yrs and under)

The law states that the parent or guardian seeking or authorizing dental treatment is responsible for paying the bill.

Any legal agreement between the parent or guardian, has nothing to do with the White Street Smiles practice. If payment for services rendered is to be paid by someone else, the parent or guardian must pay us and have the 3rd party reimburse him/her.

Missed appointments

Just as we respect your time, we ask that you return the courtesy. Call the White Street Smiles office in Danbury, CT – 203-743-4670 if you must cancel or reschedule an appointment.

If you don’t call and allow us the opportunity to fill your slot, you will be charged a NO-SHOW fee up to $75.

Questions

Thank you for taking the time to read our Financial Policy. We believe in straight-forward communication with our patients and we are here to answer any questions or concerns. Call the White Street Smiles office in Danbury, CT – 203-743-4670