Payment Policy
Same day procedures must be paid in full. Multi-day procedures must be paid in full by the last treatment date. Crowns, implants, and bridges will not be cemented until the appearance is approved by you. Changes can be made at no charge before cementing. Changes made afterwards will be at full fee.
We warranty all work for one year for breakage or fracture. Replacement will be at no cost. Replacement after one year will be at full fee.
No Show Policy
When you make an appointment at Park Cities Dental Group, we reserve a significant amount of time. Unfortunately, when a patient does not show up for their scheduled appointment, another patient loses an opportunity to be seen. Any patient that does not arrive for their scheduled appointment within a 15-minute window is considered a no-show and will be rescheduled.
New Changes in Dental Insurance Plans
Office Policies
Due to the recent and unpredictable changes within the insurance industry, we may or may not be a part of your IN-NETWORK benefits. As a courtesy, our team will continue to verify and bill your insurance, but we cannot guarantee coverage or that the information we have received from your carrier and conveyed to you is accurate or complete.
In the event that your dental insurance carrier denies your claim for "OUT OF NETWORK" and you do not have OUT OF NETWORK benefits on your plan, you will be charged a Self-Pay rate for your visit/procedure performed in our office. In the event that a particular procedure is not covered or covered at a lower rate, regardless of the estimate we provide, you will be responsible for the full quoted amount.
I understand that it is my responsibility to fully understand my insurance benefits and that the benefits quoted to me by this office are based on the information provided to PCDG by my insurance carrier. I understand that PCDG must abide by the rules governing my insurance coverage.
Financial Responsibility
WE ACCEPT LOCAL BANK CHECKS WITH A VALID TEXAS DRIVER'S LICENSE ONLY. You may pay with MC, Visa, Discover, AMEX, Care Credit, HSA, FSA, or Cash. Patients with dental insurance acknowledge that all dental services are billed to the patient directly, and the patient is personally responsible for the complete payment of all charges incurred.
Estimated payment is required at the time services are rendered. When possible, dental claims will be submitted by Park Cities Dental Group. Occasionally, insurance plans do not pay what they initially indicate. PCDG will make a reasonable attempt to resolve problems with claims; however, insurance claims not paid within 60 days are due in full from the patient.
If there remains a balance after insurance issues payment, I will receive a billing statement for the balance, which I will pay within (10) days. All balances still existing 90 days after receipt of insurance payment will be subject to recovery by a collection agency.
Notice of Privacy Practices Acknowledgment
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in my treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that your office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time at the address listed above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
