Ross Fishman, DMD, MS • William Love, DDS
I understand that the information I have given is correct and to the best of my knowledge, and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission be obtained from a parent or legal guardian before any dental services can be rendered. I give my consent to Dr. Fishman and his staff to perform such treatment, services, medication, local anesthesia and/or analgesia necessary to treat any dental/oral abnormality and/or infections.
I hereby grant authority to Dr. Fishman and his legally qualified auxiliaries to utilize x-rays, anesthetics, pre-medications, preventive and restorative procedures as may be necessary or advisable in the diagnosis and treatment of my child’s dental condition. I understand that I will be consulted before any treatment is rendered.
I understand that a minimum of 24-hour notice is required to cancel or change a dental appointment. I also understand that a $60.00 broken appointment fee will be applied to my account if the cancellation occurs without a 24-hour notice. I agree to remit the fee within one week, and no further appointments will be rescheduled until the balance is cleared. I also recognize that our office will consider waiving the fee if the broken appointment is a result of a sickness.
It is recommended that children have check-up (bitewing) x-rays at each 6 months recall appointment. This is required so that the doctor is able to diagnose any new decay in your child’s mouth since their last visit. The policy holder is responsible for outstanding balance if insurance does not cover additional set of x-rays.
It is the policy of the doctor to apply a fluoride application to your child’s teeth at each six months recall appointment. This is required to help prevent the chance of decay. Some insurance companies allow for fluoride at each of their recall appointments , while others have a frequency limitation, only paying for fluoride once a year.
Note: The policy holder is responsible for any balance if insurance does not cover additional Fluoride treatment.
Ross H. Fishman, DMD
Board Certified Pediatric Dentistry
Practice Limited to Children and Teens
To the Parents of our Patients,
Please read the following information. It will be necessary for you to sign this statement before we agree to accept assignment of payment from your insurance company. We desire to avoid any misunderstanding as a result of the increasingly complicated process of arranging payments.
Please be aware that many insurance companies are undergoing significant changes that complicate reimbursement and produce difficulties for you and your health care providers. Should repeated insurance submissions be required, there may be additional administrative charges to your account.
Filing your insurance is a time-consuming task. It is a courtesy service performed by this office which we hope to be able to continue to offer you.
Should you have any questions, please feel free to speak with our office staff.
Please indicate your understanding of the following:
I understand and agree that I am personally responsible for the payment of all examination and treatment fees on my account. If my insurance company fails to make prompt payment, or denies payment for any reason, I will be responsible to make payment for the full amount without delay.
I understand and agree that I am responsible for the estimated amount not paid by my insurance company. This portion, plus the deductible, is due at the time of the appointment, when examination or treatment is rendered. I understand that after my insurance company makes payment, there may still be a balance remaining, for which I am responsible.
I have been informed if I hold a PPO insurance, I am responsible for amounts due after insurance pays. I am aware my insurance may be OUT OF NETWORK, resulting in my out of pocket being my responsibility. The staff has informed me OUT OF NETWORK policies and procedures.
Thanks for bringing your child to our office. We consider it a privilege for our team to have the opportunity of providing you with the best dental care possible in a child friendly environment.
All of the members of our team have had years of experience treating children. Every child, though, is different. If you have some special thoughts or questions about your child, please feel free to let us know.
It is part of our practice philosophy to allow parents to be with their child in the operatory before or during treatment. This allows for increased understanding of your child’s dental needs and the means necessary to provide that care.
We will make every effort to keep our appointments on schedule. Challenges to that commitment occur on a daily basis as some children require additional attention based on their own individual background of experience.
We want to be fair to all of our patients. We ask that you work with us in scheduling your child’s appointment. If you have had a morning appointment you will have the option of an afternoon appointment for your next scheduled visit.
Payment is expected when services are rendered and can be made by cash, check or credit card. There will be a $20 charge for any returned checks. If an account becomes delinquent for more than 90 days, it may be referred to an outside collection agency. You will be responsible for any additional fees associated with the collection process, including attorney fees and court cost.
Should you have dental insurance, please check with our front office staff. We do not accept all insurance policies. Most insurance policies will only cover a portion of the fees. You will be responsible to pay your portion on the day that services are rendered. If we do not accept your policy, we will provide you with a receipt for services rendered for you to attach to the claim form provided by your insurance carrier. Insurance companies requiring multiple claims for payment may result in an insurance filing fee added to your statement balance.
Failure to give 24-hour notice may result in a broken appointment fee being added to your account balance.
As a patient at this office, the doctor and assistants will obtain information about you and record it in a health record with your consent. The practice is permitted by Federal Privacy Laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected Health Information is the information we create and obtain in providing our services to you.
Some examples of information collected in our office include: