Forms and Policies

Forms
Please print out our downloadable forms to prepare for your office visit.  Thank you!

Dental History Form
HIPAA Form
STM 1 Treatment Agreement
STM 2 Treatment Agreement
STM 3,4 Treatment Agreement
United Health Care Claim Form
Financial Agreement Form
Records Release Request

New Patient Forms
»  Click here to download our Patient Information Sheet

Insurance Policy:

We work very hard to control the cost of dental care and to be aware of each individual patient’s benefits and eligibility. It is part of our philosophy that quality care should be available to everyone. Although insurance makes maintaining dental health more affordable we feel it should not be the limiting factor for providing our patients with excellent care.

The fees we charge are the same for every patient, insured or not. Dentistry has changed very quickly; insurance fee schedules have not. After all, insurance companies are profitable businesses, not dental benefactors. As a courtesy we submit all of our patient’s dental claims to insurance with any necessary x-rays and documentation.

We do collect a minimum estimated out of pocket at the time of service and we do this by knowing our patients benefits prior to their appointment. After we receive payment from insurance any amount not covered by the insurance company will be the full responsibility of the patient. Any deductibles and co-pays will be required at the time of service. Each policy is different, but in general, insurance usually covers about 100% of preventive/diagnostic care, 80% of minor restorative care, and 50% of major work.

If the patient is ever curious about their coverage or what their out of pocket would be for different services they are welcomed to call our office to ask. We do urge our patients to do a pre-authorization for any major procedures and they are welcomed to get pre-authorization on restorative if they want an exact out of pocket. All treatment plans and charges will be discussed so each patient is completely comfortable and informed with the financial aspect of their dental care.

New Patient Policies and Information:

We require new patients to go through hygiene first and get their teeth cleaned before doing any restorative or major work. At your first appointment you will need to bring your dental insurance card and the policy holder’s social security number and birth date if it is someone besides yourself. We will need you to fill out a patient information sheet (if you are taking any medications regularly you should bring this information with you to assist in filling out the paperwork) and an authorization and release form. If you are filling these forms out at our office you will need to be here 10 minutes early. These forms can be downloaded on this website or emailed to you upon request. Please view our cancellation and insurance policies.

Cancellation Policy:

We make every effort to be on time for our patients, and ask that you extend the same courtesy to us. If you cannot keep an appointment, please give us at least 24 hours notice. This courtesy on your part will make it possible for us to give the appointment to another patient who needs to be seen. We understand that situations may arise that would make it impossible for you to give 24 hour notice and each incident will be given consideration based upon your appointment history. Missed or broken appointments without notice may be charged to the patient account. The broken appointment fee is $25.00.

 

 

 

Creating Smiles For Life

Dr. John C. Carter, DDS
4907 Brambleton Avenue • Roanoke, VA 24018 • (540) 774-3143