Welcome to Adirondack Orthodontics! The following is a statement regarding our financial policy. Please review and sign the policy to proceed with treatment. Unless previous arrangements have been made, all payments are due on the monthly date selected by the responsible party. Payments may be made by cash, check, credit card. We do participate with CareCredit and accept most FSA/ HSA cards.

DENTAL BENEFITS

We are pleased that many of you have dental benefits, and our office will assist you in obtaining the maximum benefits specified in your contract. However, your benefits are a contract between you and your insurance carrier.

We will assist you in determining your benefits as best we can. Plans differ from carrier to carrier and policy to policy, our office may refer you to your carrier or your employer’s human resources for assistance in understanding your plan.

Our practice is committed to providing the highest quality of treatment to our patients and we charge usual and customary rates for services rendered. We know how confusing insurance plans can be. If you have any questions, feel free to ask us. We may be able to help you.

ADDITIONAL FEES

Returned Check Fee

A $40.00 fee for returned or “bounced” checks will be applied to the patient’s bill if this occurs.

Aged Accounts

If your account becomes delinquent for more than 90 days, you agree to pay a finance charge of 1.5% per month on any balance due, attorney fees and interest fees accrued with the collection of this account.

Appointment Policy

We respect your time, and we ask that you respect our time by honoring your appointment commitment. Remember, once you have made an appointment, this time is reserved for you. Please give us at least 24 hours notice if you are unable to keep your appointment. This will allow us to accommodate the needs of other patients more readily. If we do not receive a cancellation notice within 24 hours, a cancellation fee of up to $50.00 per visit/patient may be applied to your account.

Lost or Broken Retainers

Lost or broken retainers or any appliance will result in additional charges to your account. Please contact your local office for more information on retainer replacement charges.

Additional Appliances

If an additional appliance is needed during treatment due to unpredictable circumstances, there will be an additional fee applied to the account after proper consultation with the patient’s responsible party.

Extended Treatment

If treatment time extends beyond the original estimated time due to non-compliance, there will be an extended treatment monthly fee of $150.00 until treatment is completed.

Broken Brackets

Normal wear and tear on appliances is expected. Unwarranted breakage, more than five (5) loose brackets, or loss of appliances will require an additional charge of $15/bracket.

Interest- Free Financing

Adirondack Orthodontics offers interest-free financing with automatic payments. Valid credit card information must be supplied at the time of contract signing to be eligible for interest-free financing. Should an automatic payment be declined at any point, the payment must be made and credit card information updated within thirty days, or a penalty surcharge of $250 will be applied.

Late Payments

If a payment is 30 days late, a 30- day letter will be sent to the party responsible. During this month, the patient will be seen, and active treatment will continue.

If the account falls 60 days past due, late charges will be applied on both overdue payments. No active treatment will occur until the account is brought up to date (we will check for broken or loose appliances and evaluate hygiene until the account is brought current).

If the account falls 90 days past due, further late charges will be applied, and a termination letter will be sent by certified mail. This will terminate our responsibility to the patient. If the patient finds alternate financing and pays the entire unpaid balance, active treatment can be reinstated.

Responsible Party

For patients under age 18, the responsible party is the parent /guardian who accompanies the patient and completes the child(ren)’s paperwork. This may or may not be the parent under whom the child is insured. Court documentation may be required in cases of divorce/separation to determine the financially responsible parent/guardian.

Dental Insurance

Insurance Benefits

In Network Coverage – Your insurance company will reimburse us according to the provisions of your policy; We will bill your insurance for you and assign benefits to be paid to us directly. In addition, if for any reason your insurance denies coverage or coverage is lost during treatment, you are responsible for any unpaid insurance balance.

Out of Network Coverage – Often a pre-treatment estimate is necessary to determine what benefits are available to you and we will be happy to provide that information to you at your request. Once you have verified that you are entitled to orthodontic benefits under your dental care plan, our office will submit your claim forms containing all the necessary information required by your insurance company. If additional forms must be submitted after treatment is initiated, it will be your responsibility to notify us so we can submit these forms. Your insurance company will reimburse you according to the provisions of your policy. Since professional services are rendered to you and not to your insurance carrier, you are responsible for the fee arrangement and its payment schedule; your insurance carrier is responsible to you for payment of the benefits to which you are entitled. In addition, we do not have a contract or agreement with insurance companies to render services to their policy holders and, therefore, do not accept payments determined by the insurance company to be payment in full for these services. If for any reason your insurance denies coverage or coverage is lost during treatment, the financially responsible party is responsible for any unpaid insurance balance.

Secondary Coverage– Your contract is based upon estimated payment from your primary insurance. In the event of secondary insurance coverage, benefits will be determined according to the insurance company’s coordination of benefits policy. If you wish to utilize secondary insurance benefits, be advised that you are responsible for payments according to the contracted payment schedule until such time as payment is received from the secondary insurance. In the event of overpayment, appropriate refunds will be issued.

Social Security Number

To carry a balance at our office, we require your social security number. Carrying a balance at our office is when we submit to your insurance and await payment on the claim. Ultimately, you are responsible for any portion of your claim that the insurance does not cover. Without your social

security number, we are unable to collect an unpaid balance in the event a patient would default on paying the balance after 90 days.

Alternatives to giving your social security number: 

  • Paying up front insurance fees for all visits and being reimbursed upon payment from the insurance
  • Filling out a credit card authorization form (providing your credit card number) so that we may charge any unpaid (by the insurance) amount upon settling of claims
  • Cancelling your appointment

We understand that your privacy is your priority. It is our priority as well. Please note this policy is simply in place to safeguard our practice so that we may continue to accept insurances and affordable care.

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