Office Policy

THIS INFORMATION IS AVAILABLE AS A DOWNLOABLE PDF – PLEASE SEE FORMS PAGE • I have received or downloaded and read a copy of the Privacy Practices for the Dental Office of John Toumanios, DDS. • Payment is due when treatment is rendered, unless other arrangements have been made. • Appointment times are reserved exclusively for you. If you are unable to keep your appointment, twenty-four hour notice is required, or you will be charged $50 per half hour scheduled. (We have reserved 45 minutes for your routine hygiene appointment.) • Your insurance policy is a contract between you and your insurance company. You hereby authorize us to release information to your insurance company on your behalf. • We will submit all claims for you, more than once of necessary. Ultimately, however, you are the one responsible for payment of the account. Co-pays, deductibles and non-covered fees are due when services are rendered. • The parent/guardian signing is responsible for this account, regardless of the subscriber of the insurance policy holder. • A balance outstanding over thirty (30) days is subject to 15% interest. This will be extended if financial arrangements have been made. • In the event of legal action necessary to collect an unpaid balance due for dental services, I agree to pay reasonable collection and attorney fees or other such cost as the court determines proper and consent to obtain credit report, if necessary. • If there is any change in my health or medication I will inform the dentist at the next appointment.