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PRINTABLE FORMS TO FILLOUT PRIOR TO FIRST APPOINTMENT

Office Policies

Thank you for selecting us as your personal dental care team. To promote a long-term and mutually satisfying relationship, we would like to explain our office policies regarding treatment, insurance, appointments and fees. Please read this carefully and let us know if you have any questions or concerns before treatment is rendered. Submission to treatment indicates that you consent to and agree with the terms of our policies as explained in this document.

TREATMENT:

You will find our entire office staff is dedicated to helping you improve your dental health as efficiently as possible. Every effort will be made to make your visit comfortable and pleasant. Our goal to provide you with the best dentistry available and your diagnosis will be based upon your individual needs. We assume you are just as concerned as we are about maintaining good oral health ... therefore, it is important that we do not allow dental insurance to be a determining factor in what treatment will be necessary to maintain your proper dental health. Example: We use only the best BPA-free resin (tooth colored) filling material and do not use amalgam (silver) due to its mercury content; we advise you to call your insurance company to obtain their policy on resin fillings. Please feel free to discuss your treatment with the doctor at any time.

INSURANCE:

Your insurance may not cover your services or may only partially cover them. Any estimate given by this office is considered a guideline; we make no guarantee of what your insurance company will actually pay. We will electronically file your primary dental insurance for you. Be aware that we are out of network with all insurance companies so calling your insurance to get the information of what your insurance will pay is the patient's responsibility; if your insurance pays you directly, you're in full balance is required at each visit. Your coverage is an agreement between you and your insurance carrier; it is your responsibility to be informed of your dental benefits and eligibility and to inform us of dental insurance changes. Even if our office is able to accept direct insurance assignment, the patient is still fully responsible for the charges for treatments rendered.

APPOINTMENTS:

The time you choose for your appointment is reserved especially for you. We do not double book. To ensure you receive the best standard of care and treatment, our staff prepares for your appointment by sterilizing, organizing and arranging the setup of items prior to your arrival. ln order to provide all of our patients with the same high standard of care, we require a minimum of 24 hours' notice for cancellations and reschedules. This will afford us adequate time to notify patients who are in need and on a waiting list for the first available appointment. lf you No show to your appointment or do not provide a minimum of 24 hours' notice to cancel or reschedule, a fee of $50.00 will be charged. The second missed appointment will be charged a fee of $50.00.  The third no show you may be discharged from the practice. No future appointments or record transfer requests will be scheduled or honored until your total fees are paid. lf you are 15 minutes or later for your appointment, it will be considered a no show and you will incur the $50.00 fee and will have to be rescheduled, this is to keep all patients on schedule as much as possible.

PAYMENT:

Full payment of your charges or copay is expected at time of visit. We accept cash, personal checks, MasterCard, Visa, Discover and American Express. Payment arrangements may be made for patients needing extensive dental work; payment arrangements must be approved and in writing before services are rendered. Returned checks will have $30 fee and will have to be paid in full before future appointments will be made. All balances over 90 days will be turned over for collection unless arrangements have been made in writing beforehand with office. 

COVID-19 Precautions

If you have any symptoms of COVID-19 or have been recently out of the country, please call our office before entering.

If you have been exposed to COVID-19 recently, please call (716) 372-8440 to reschedule your appointment.

Thank you for your cooperation,

J. G. Stein Dentistry Staff

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