If you have dental insurance, we will accept assignment directly from your primary insurance company if you agree to the following terms:
I am responsible for the payment of all treatment fees on my account.
I am responsible for the estimated portion not paid by the insurance company at each visit. If the estimate of insurance benefits indicates a large amount due by me and I feel I cannot pay it during treatment, I can request a written financial agreement. (Terms to be discussed at that time).
If upon payment by the insurance company, there is a remaining balance, I am responsible for the amount in full at that time.
If my insurance company fails to make payment within 60 days, I will be responsible for the amount in full at that time.
For delinquent account, beyond 90 days, I agree that the office of Dr. Grace Hsu reserves the right to pursue the full payment through collection agency service at my own expense.
Please be aware that some of the services provided may not be covered or may be reduced to an alternate benefit under your insurance plan. For example, most insurance companies will reduce their benefit for composite (white) fillings to the benefit for an amalgam (silver) filling. This will result in a higher out of pocket expense, as our office does not perform amalgam fillings.
Our office does not accept assignment from secondary insurance.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
Minor Patients : The adult accompanying a minor or the parents/ guardians of the minor are responsible for full payment
Interest : It is the office policy to assign a late charge of 1 % per month on any unpaid balance over 60 days.
Unless cancelled, at least 48 hours in advance, our policy is to charge for missed +/ broken appointments at the rate ($50) of a normal office visit. Please help us serve you better by keeping scheduled appointments.
We appreciate your concern in our need to enforce these policies in order to deliver to you, our valued patient, continued optimal care. Please let us know if you have questions or concerns.