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  • We, at ABC123 Pediatric Dentistry would like to welcome you to our practice. Dr. Diaz believe in creating vibrant and healthy smiles for your children, using the most advanced quality dentistry, supplies and digital x-ray to exceed their patient's and parents expectations. Because we value our relationship with you and believe the best relationships are based on understanding, we offer this clarification of our methods of payment for services.

    • Payment is expected at the time in which services are rendered.
    • For your convenience we accept Visa, Master Card, Discover, American Express and Care Credit. We do not provide in-house payment plans.
    • Due to COVID-19 we are not longer accepting cash.
    • We do accept insurance assignment. Insurance coverage and patient portion amounts are only an estimate.
    • Guarantor is responsible for all services rendered. We attempt to provide the most accurate information available; however, insurance carriers will not guarantee their information. Therefore, we regret that we can not be responsible for any discrepancies in estimated benefits.
    • Your dental insurance policy benefits are strictly between you and your insurance company. We are not a third party to that contract. We will provide our best service in submitting and collecting your insurance benefits. However, please keep in mind that any information regarding your benefits given to you by our office is a courtesy; you should verify and be knowledgeable about your insurance benefits. Our staff is dedicated to helping you receive the ultimate benefits available under your policy.
    • Regardless of the reason, if the insurance company fails to pay their estimated portion within 60 days of the date of service, the balance in full is due at that time by the responsible party.
    • In the event of a duplicate payment, our office will issue you a refund. Regardless of payment type, all refunds will be by check, mailed to you. Please allow at least two weeks for all refunds.

    When you schedule an appointment for your child, time is exclusively reserved for your child. We make every attempt possible to confirm appointments via phone call, email and text. If you are unable to keep your child's appointment, please inform us 48 hours prior to the appointment. This allows us time to schedule other children who are waiting to receive treatment. If you fail to give us a 48 hour notice, the following fees will apply:

    • IV Sedation or Hospital Case forfeiture of deposit
    • All other appointments $50 per appointment per patient

    If you're bringing your child for a second opinion and you are bringing x-rays, the x-rays must be from the last six months and diagnostic. The doctor cannot diagnose without x-rays, therefore if the x-rays provided are not diagnostic and we have to take our own, a fee will apply depending on the type of film. In the event that you want a copy of the x-rays taken here, a $25.00 fee will be applicable.

    There is a global limited supply of personal protective equipment (PPE). Therefore, the cost has increased dramatically and our office can only absorb a portion of it. As a result, a fee of $10 per patient per visit will be charged. We will bill your insurance for reimbursement and if they pay, your account will be credited.

    All patients under the age of 18 must be accompanied by their legal guardian at each visit. If someone other than the legal guardian brings the patient, we must have a signed letter of authorization from their legal guardian for each visit that they are not accompanied.

    • The purpose of this letter is for the protection of your child. We ask the guardian to authorize the person bringing the child to the visit to make all legal, medical and dental decisions for the child's dental visit.
    • If you are not comfortable with someone else making these types of decisions for your child, we recommend you bring your child. In the event of an emergency, this person will be asked to make decisions on behalf of the patient.
    • Payment arrangements, if any for that date of service, should be planned accordingly with the person bringing in your child. Appointments can be prepaid over the phone. The person bringing the patient to their visit must have valid identification with them or appointment will be cancelled.

    We look forward to not only maintaining an informative relationship with you and your child but most importantly maintaining your child's oral health and making each visit enjoyable. Please feel free to ask for a copy of this policy after acknowledging it.

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