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Dear Parents
We are pleased to welcome you to our practice! Thank you for selecting our office to evaluate and car for the dental
needs of your child. We are excited you are here!
We strive to ensure a positive dental experience for all of our patients. We ask for you cooperation in helping us to use
our Pediatric terminology provided in this packet for any of your child’s appointments.
The mission statement of our practice is “To create Small Joyful Smiles one precious smile at a time”.
It is our preference in most all cases to have parents wait in the waiting area for your child’s restorative and exam visits.
In our experience, children tend to relax more when parents/guardians are not present. However, sometimes this is not
the case. As needed we may ask you to be present for your child’s visit. When you are present, we suggest the following
guidelines to improve the chances of a positive outcome.
Allow us to prepare your child.
Be supportive of the practices terminology
Be a silent observer and support your child at all times to render the best dental care possible
This allows us to maintain communication with your child
Children will normally listen to their parents over the dental team
Incorrect or misleading information may be inadvertently given
We will continue to support your child at all times to render the best dental care possible
There may be a time outside of oral sedation or general anesthesia that we ask you to stay outside the treatment room.
Oral sedation and general anesthesia is always dental team only for parent and child safety. These are very important
ways that our office can successfully help your child. It is our hope that these guidelines will help prepare your family
with confidence for their upcoming dental visit. Thank you again. If you have any further questions, please call our office.
Thank you very much!
Dr. Sheva, Dr. Kim and our Thrive Pediatric Dentist Team
Parent acknowledgement of Receipt of Guidelines X_____________________________________________________
Thank you for choosing our practice for all your child’s health care needs.
We look forward to providing an enjoyable and positive experience for you child.
Here are some terms/words we like to use:
WELCOME TO OUR PEDIATRIC DENTRISTRY.
Dr. Sheva, Dr. Yoon Kim Hee and our Thrive Pediatric Dental Team
Phone:_______________
Phone:_______________
Phone:_______________
Phone:_______________
Patients Name (Please Print) Parent/Guardian Name (Please Print)
Financial Policy Dr. Sheva Nickravesh
Please note all estimated copays are expected on the day service is rendered. We accept cash, most major credit cards, checks and care credit to assist you with obtaining care for your child’s dental needs. Our entire staff is pleased that you have insurance benefits to help you and your family with the cost of your child’s dental care. With this in mind, please read the information below on our insurance claims process so we can work together to ensure your benefits are maximized.
DO YOU ACCEPT MY INSURANCE? HOW MUCH WILL THEY PAY? We currently accept several private insurance plans, meaning that we work with multiple insurance companies. Although we maintain computerized histories of payment by a given company, they do change; therefore, it Is impossible to give you a guar-anteed quote at the time of service. We estimate your portion based on the most up-lo-date information we have, but it is only an estimate.
I THOUGHT I PAID MY PORTION, BUT I RECEIVED A BILL. WHY? We base the payment portion of your estimated treatment plan on our most current data, but there are several factors that can affect this estimate. For example, there may be a deductible, or you may have received treatment in another office prior to join-ing our office. Some insurance companies downgrade certain types of services. For example, a composite (tooth colored) filling is done and the insurance company downgrades to pay for an amalgam (silver) filling. Insurance companies do not inform us of any changes to your benefits. We do, however, investigate your benefits as thoroughly as possible. An often-misunderstood term used by many insurance companies is "UCR". This is an arbitrary fee ceiling at which the insurance company will stop reimbursement. These fee ceilings were often set 10-15 years ago. After this ceiling, coverage for a particular procedure may cease, meaning that the patient will have an extra portion that is due. Despite our best efforts at giving you an accurate estimate, a patient will occasionally owe that amount of the difference. Again, this has nothing to do with the fee charged but the level of coverage negotiated by the insurance company.
INSURANCE DID NOT PAY, NOW WHAT? We bill your insurance as a courtesy. Dental insurance is a contract between your employer and the patient or directly between you and your insurance company. It has no connection at all to us as your dental office. The extent of coverage varies greatly from company to company, sometimes even within a company. It has absolutely nothing to do with the level of service provided by us, and the fee for these services. If your insurance company has not paid within 60 days from the date of service, we will send the full balance on the account to you. This allows for you to join in our efforts of having your insurance claim paid by your insurance company. We do ask for payment within 30 days of receiving a statement. At 120 days from the date of service, ac-counts are sent to collections. It is our financial office's goal to assist you with paying your balance; however, we do ask you to remain in communication with our financial team.
CANCELLATION POLICY If you are unable to keep your appointment, please notify our office 48 business hours scheduled time. For example: If your ap-pointment is on Monday, you would need to call by the Thursday before. A $25 missed appointment will be charged per child to your account if proper notice is not received, $25 for continuing case and $50 for treatment case. If your child is scheduled for oral conscious sedation, the fee per child for improper notice is $100.00, the equivalent of the first hour of anesthesiologist. Se-dation payment (oral or general anesthesia) is forfeited if the appointment is not kept.
RETURNED CHECK POLICY There will be a $25.00 handling fee for all returned checks and an $8.00 fee from the bank. Once we have received notice of a returned check, we will try and contact you to rectify the payment. However, after a few failed attempts to reach you the re-turned check will be handed over to the proper agencies. We ask should you find yourself in this situation to please be in contact with our financial team.
Financial consent I consent for my insurance company to render payment to Dr. Sheva Nickravesh I have read, understand and accept the terms of the above outlined policies for insurance handling and financial commitments that that I may incur as a result of my child’s treatment..
