Office Policies Form

Sunrise Family Dental Care’s staff of qualified dentists, hygienists and other support personnel hope to provide you and your family with quality dental care for years to come. Our goal is to educate all of our patients to the best of our abilities about their dental needs. In order for us to accomplish this task, it is necessary that we also have the utmost cooperation of our patients to ensure their dental health does not become compromised. Our trained team will treat you and your family in the most professional manner and will always be willing to answer any questions you may have regarding your treatment or our office policies.

In assisting our team to accomplish Sunrise’s goal of dedication, a number of policies have been implemented to help us serve you better and ensure better overall patient care. We ask that you take a few minutes to review just acouple of these policies before we begin our relationship.

INSURANCE AND PAYMENT FOR SERVICES: We are primarily a “fee-for-service” dental practice however, we also accept patients who participate in a variety of dental insurance plans as well as patients who have no insurance at all. Regardless of a patient’s insurance status, the fees associated with any treatment will be due and expected at the time of service. As a courtesy, we will make an honest effort to give those patients with insurance coverage an estimate of what they can expect their insurance to pay. The amount which is not covered by insurance (i.e. the “co-pay”) will be expected to be paid by the insured at the time service is rendered. In any event and for whatever reason an insurance company declines to cover the cost of the treatment rendered in our offices, the patient/insured will be responsible for the outstanding balance. Although we will make every reasonable effort to obtain insurance benefits from the insurer, the ultimate responsibility falls upon the patient/insured to resolve disputes with their insurance company(ies). This is a contractual relationship between the patient and the insurer; not the insurer and the dental office. We ask patients to direct ALL financial and/or treatment fee questions to the office Financial Coordinator or Office Administrator.

SCHEDULED APPOINTMENTS: Patients’ scheduled appointments are just that - scheduled appointments! We make every effort to arrange a convenient time for our patients to attend to their dental needs. Further, in an effort to remind patients of their appointments, an appointment card or recare card is given or sent, respectively, to our patients, as well as a courtesy phone call being made at least two (2) days prior to the scheduled appointment. Preferably, our office would like 48 hours notice if you are unable to keep your scheduled appointment. At a minimum, we require 24 hours notice. In the event our patients are unable to give (at least 24 hours) notice that they cannot keep their scheduled appointment FIFTY DOLLAR ($50.00) charge per appointment will be assessed against their account to offset the overhead costs for this opening in the office’s schedule. We prefer not to charge this fee. A simple call by you, the patient, will relieve you of this financial burden and allow our office to fill the opening with a patient in need of immediate dental care. Thank you in advance for your assistance in this matter.

PAYMENT: Our offices accept VISA, MasterCard, Discover, Care Credit and American Express credit cards for payment. We also accept cash, personal checks (no third-party checks), cashier’s checks and money orders. Certain patients may qualify for time-payment contracts or a line of credit through, an independent finance company! If you have any questions regarding payment, please ask the office Financial Coordinator.

As a patient you have the responsibility to attend to your dental needs both at our offices and at home. Neglecting your dental needs can and surely will lead to greater complications as you get older. Our offices will advise our patients of the recommended course of treatment - It is the patient’s ultimate decision, however, whether or not he/she wishes to participate in this course of treatment.

I ACKNOWLEDGE I HAVE READ and REVIEWED THE ABOVE POLICIES OF SUNRISE & IT’S AFFILIATES. I HAVE HAD THE OPPORTUNITY TO ASK ANY QUESTIONS REGARDING THESE MATTERS PRIOR TO BECOMING A PATIENT OF SUNRISE.