In order to allow the best possible care for your child, we reserve a specific time just for you and make every effort to see your child as scheduled. We appreciate your promptness and your consideration in not changing your scheduled time. However, if you need to change your appointment, a 24-hour notice is required. If at least 24 hours notice is not given to change or cancel an appointment, or if you miss your scheduled appointment, we reserve the right to charge a fee of $50 for the missed appointment. If your child is unable to be seen because you are more than 10 minutes late for your appointment, you may also be charged the $50 fee for a missed appointment. Patients with two missed appointments may be required to transfer their records to another dentist.
For your convenience, you may download and print necessary office forms. We ask that all of these forms be completed in advance and brought to your first visit. This will allow your child to be seen on time as scheduled. All forms are .pdf documents. Just Call (843) 556-1655 and schedule your kids an appointment with our dentist in Charleston, SC.
Medical History Form
Acknowledgement of Receipt of Notice of Privacy Practice
Authorization to Release Healthcare Information
CCD Permission Letter
Your dental insurance is a contract between you and the insurance company. To assist us in determining your maximum benefit, please bring your insurance’s explanation of benefits booklet and your dental insurance card to your first visit. We will file your primary insurance claim as a courtesy to you. Although we may estimate what your insurance coverage may pay, it is the insurance company that makes the final determination of your eligibility and benefits. Most insurance plans only pay a portion of the dental fee. Therefore, we ask that you pay the non-covered balance at the time of service unless other arrangements have been made with our office in advance. If your insurance company has not paid on your account within 45 days, you will be responsible for the unpaid balance, and payment will be expected in full at that time. We recommend that you become directly involved in communication with your insurance company in order to expedite payment.
Payment is due at the time of service unless you have made prior arrangements with our office. We accept cash, personal checks, Visa, and MasterCard. The parent or legal guardian who signs the financial policy is considered to be the responsible party for account payment.
Sedation Reservation Fee
A reservation fee of $100 is required to make an appointment for a sedation visit. This fee will be applied to your bill on the day of the sedation appointment. If the appointment is missed or if the patient is excessively late, the fee will be kept as a missed sedation appointment charge.
SCDA Action Alert Important Information Regarding Section 1557
By now you have most likely heard of Section 1557 of the Affordable Care Act (ACA) that was designed to protect individuals from discrimination in health care. The Office of Civil Rights (OCR), which currently enforces HIPAA, will be enforcing Section 1557 as well.
Dentists and dental practices that receive certain payment from the U.S. Department of Health and Human Services, such as Medicaid or CHIP reimbursement or “meaningful use” payments under the Medicare and Medicaid Electronic Health Records Incentive Program must comply with Section 1557. Additionally, the final rule applies to a dental practice that receives reimbursement under Medicare Advantage (Medicare Part C), whether the plan reimburses the dentist or the patient.
These practices must have certain notices displayed in their practices and on their websites by October 16, 2016. They must be included within certain publications as well.
There are 2 notices to display and below are links to those notices. One is for practices who employ less than 15 employees and the other is for larger practices. The larger practices must assign a team member as the grievance coordinator and have a grievance procedure in place, therefore their notice differs from that of a smaller practice. These forms are electronically writable, but you must first be sure to download them to your computer.
Regardless of size, all practices impacted by Section 1557 will utilize the below “ADA Taglines” as the second notice and it contains the 15 most commonly used languages in our state.
The final link contains a list of translators that you may utilize should you so choose. These companies are not endorsed and/or sponsored by the SCDA in any manner. This list is provided as a simple reference only.
Below is a link to the ADA’s Centers for Professional Success and it has a wealth of information regarding Section 1557 of the ACA. This is a member benefit, so you must log in with your ADA number in order to fully view this link.