Dental Services

Welcome to the Bureau County Dental Clinic. We are glad you chose us for your oral health needs. Our staff here at the dental clinic values your time and we hope you will in turn value our time. We have a few office policies that we would like you to review and sign. Agreeing to these policies will enable us to provide better care to you in a more timely and efficient manner.

1. All payment for services performed are due at the time of service. Eligibility for services under the Illinois public aid card will be determined before the start of each visit. You will be required to bring your current medical card to each appointment since eligibility may change from month to month.
2. The only form of dental insurance that is accepted by this office is the Illinois Public Assistance Card (Medicaid). Other forms of insurance will not be processed.
3. Any performed services that have been denied by public aid will be your responsibility to pay.
   
4. Not every treatment you might need is covered by the public aid insurance. Our office has no control over what is covered and what is not.
   
5. Not all covered benefits are offered by our practice.
   
6. Some of your dental needs might require the care of a dental specialist. If that is the case you will be referred to one. Be aware that more specialists DO NOT accept the public card. All clinical decisions are made at the sole discretion and professional judgment of our attending dentist and they are final.
   
7. Patients with outstanding balances for dental work will not be seen until all balances are paid in full. Absolutely NO exceptions will be made.
   
8. If you need to cancel an appointment, we require a 24-hour notice. A fee might be assessed for each failed visit or you might not be able to reschedule an appointment.
   
9. If you are more than 10 minutes late for your scheduled appointment, you may need to be rescheduled; a fee might be assessed.
   
10. Any unfinished dental work regardless of the reason for which a Lab bill has accrued will be your responsibility to pay.
    
11. Any patient that has failed (missed and or cancelled) more than one appointment will be dismissed from Dental Clinic. NO Exceptions!
    
12. In appropriate and/or rude behavior is cause for dismissal from the practice. Absolutely NO Exceptions will be made.
    

I have read and understood the above policies and agree to them. I further agree that I am responsible for any charges not paid by the public card.

Patient/Guardian Signature______________________________________

Date_______________________________