Office & Financial Policy Form

Office & Financial Policy

Thank you for choosing the dental office of Douglas J. Kosek DDS, PC, where your oral health is our number one concern. We will make every effort to ensure that all fees are fair and reasonable. In order to reduce any confusion or misunderstanding, we have adopted the following policies.

• Please provide your current dental insurance before your appointment. If you need more plan-specific information about your benefits, please contact your insurance carrier.
• We are in-network with Delta Dental, Cigna, Paramount, MetLife, and Guardian. As a courtesy, we do file to a variety of other insurances, excluding Medicare and Medicaid.
• Monthly statements will be sent to all accounts that do not have pending insurance claims, even those with orthodontic balances.
• All payments including co-pays and deductibles are due at the time of service unless prior arrangements have been made.
• A $25 fee will be assessed to all returned personal checks. Any returned check must be taken care of to avoid being turned over to a collection agency.
• All delinquent accounts that carry a balance for over 90 days will be turned over to a collection agency unless proper arrangements have been made. We utilize a collection agency (Capital Accounts & Diamond and Diamond) when we cannot make arrangements with patients for payment on the account. Once turned over you will be responsible for taking care of your balance and any collection fees incurred.
• A 24-hour cancellation notice is required for ALL appointments. Please keep in mind that this is a spot taking up your hygienist's and/or doctor's time.

I have read, understand, and agree to the Office & Financial Policy.

** For patients 17 years and younger: a parent or guardian must accompany them and sign the Office Policy form (exception; patients under 17 years of age declared emancipated minors). It is the parent/guardian's responsibility to bring the necessary insurance card and to make any payment due at the time of service.