Gallery

General Release of Information

I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]

Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

Insured Patients:

As a courtesy, we will process your insurance claims for you. Please understand the following:

1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
6. All charges are your responsibility regardless of any insurance benefits.

All Patients:

Please be aware of the following:

1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
2. The charge for each returned check is $50.00.

General Release of Information

I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]

Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

Insured Patients:

As a courtesy, we will process your insurance claims for you. Please understand the following:

1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
6. All charges are your responsibility regardless of any insurance benefits.

All Patients:

Please be aware of the following:

1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
2. The charge for each returned check is $50.00.