OFFICE Forms & POLICIES

FORMS

Patient Health History Form (PDF)

POLICIES

Appointments

Your scheduled appointment is reserved specifically for your child. Any change in this appointment affects all of our patients. If a cancellation is unavoidable, please call the office at least 24 hours in advance so that we may give that time to another patient. If two (2) broken/missed appointments occur or two (2) cancellations without 24-hour notice, our office reserves the right to NOT schedule any subsequent appointments. Also, if you arrive 10-15 minutes late for your appointment, you may be asked to reschedule for the next available appointment time. Again, please call at least 24 hours in advance if a cancellation is unavoidable so that we may give the appointment to another patient.

Appointments for young children are typically scheduled in the morning.   Treatment appointments are much easier when your child, the doctor, and staff are fresh.

Recall appointments are typically made six months in advance for your convenience. 

We strive to see all patients at their scheduled appointment time. We will make every effort to see your child on time.  Please remember that working with children is unpredictable, thus, we run on children's time, not adult time.  Additionally, there are times when our schedule is delayed in order to accommodate an injured child or a child in pain. Please accept our apology in advance should this occur during your appointment. We will provide you the same courtesy if your child is in need of emergency treatment. Please let our front desk staff know if you have been waiting longer than 15 minutes.   

Please plan to arrive 5 minutes or more before your scheduled appointment. This will allow time to complete any additional paperwork and see your child on time.

A parent or legal guardian (with official documentation) must be present in the office during the initial examination and any subsequent treatment appointments.

Payment

We will accept assignment of benefits from your insurance company, however, you will be responsible for the full balance including any amount that is not paid by your insurance company. Payment is expected in full for each appointment as services are rendered. We accept cash, personal checks, MasterCard, or Visa. If you have any questions regarding insurance or payment arrangements, please let us know and we will be happy to provide more information.

In certain unusual circumstances an account balance may occur. Rossitch Pediatric Dentistry requires all outstanding balances to be paid in full by thirty (30) days unless other arrangements have been made. Also note, if we have not received payment or you have not contacted us within thirty (30) days, further action may be taken with a collection agency or with Small Claims Court. We reserve the right to apply an interest rate of eighteen percent (18%) from the date of service. Thank you in advance for your understanding of our financial policy! As always, we are always happy to answer any questions.

Insurance

We are happy to file your insurance claim as a courtesy.  However, there is no direct relationship between our office and your insurance company. The type of plan chosen by you, and/or your employer determines your insurance benefits. As such, we have no say in the selection of your insurance company, no control over the terms of your contract, the methods of reimbursement or the determination of your insurance benefits. We will accept assignment of benefits from your insurance company, however you are responsible for the full balance including any amount that is not paid by your insurance company.

Pre-treatment Authorization

Some insurance companies recommend an estimate of the work to be done and the fees to be charged before determining their benefits to you. If so, we will provide you with the pre-treatment fee estimate. In this case, it will be up to you to decide if you wish to proceed with treatment before the insurance benefit is determined.

Phone Calls

Telephone calls about billing or scheduling are taken by our appointment/account coordinator during regular business hours.  If your child has a dental problem, please call early in the morning and leave a detailed message.  A Rossitch Pediatric Dental team member will return your call as soon as possible. 

Parents Participation and Safety

At Rossitch Pediatric Dentistry, we strive to achieve a balance between allowing parents to be a part of their child’s dental experience and allowing children to feel comfortable and confident enough to undergo dental treatment on their own.  With this in mind, one parent is invited back to observe during the initial examination or during an emergency examination.  Additionally, a parent is always welcome to accompany a child 3 years old or younger to any subsequent treatment appointments.  However, if we feel that your presence is having a negative impact on your child’s behavior, you may be asked to step away from your child’s field of vision.  We strongly encourage you to allow your older children to undergo their dental experience on their own.  This arrangement allows the doctor and staff to communicate with your child directly without distractions, and usually results in a more positive experience for your child.   If we feel that your presence will benefit your child, we may ask you to join us in the treatment area.  We are happy to discuss other arrangements under special circumstances, but please be aware that such accommodations may only be made for select appointment times.  During sedation and treatment at the hospital, no parents are allowed to observe due to safety concerns.

For safety and privacy of the other patients, all others (including children that are not scheduled at this appointment) are asked to remain in the reception room. Young children in the reception room will need a supervising adult.

The use of cellular phones is prohibited in the treatment areas. Conversations carried on by others in the clinical area can be very distracting to children, thus preventing us from close, careful communication with each young patient.

Finally, if you expect your child to do well and enjoy their visit to our office, chances are they will do just that! Thank you for your understanding and cooperation in these matters.

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