We Want to Welcome You
as Our New Patient!

Important Information

Patient Bill of Rights

• You have a right to be treated with respect, consideration, and dignity by doctors and team members in this dental practice.
• You have a right to privacy as it relates to your patient information and dental care. Patients shall be assured confidential handling of their dental and financial records and may approve or refuse their release, except when required by law.
• You have a right, to the degree known, to receive information regarding your dental diagnosis, treatment, prognosis, alternatives, associated risks, and the expected cost sufficient to assure an informed choice.
• You have a right to accept, defer, decline, or dispute any part of your treatment.
• You have a right to ask for an alternative treatment option even though a dentist may decline if they are harmful, experimental, or contrary to prescribed dental practices.
• You have a right to expect dental team members to use appropriate infection control and sterilization methods.
• You have a right to know the education and training of your dentist and dental team.
• You have a right to refuse participation in scientific research.
• You have a right to change dentists within the practice or transfer to another dental office.
• You have a right to be informed of the wide range of dental services available to you.
• You have a right to after-hours and emergency care should the need arise.
• You have a right to be informed of the payment/financial policy.
• You have a right to express grievances or make suggestions by submitting them in writing to: contact@dentist4.com

Patient Responsibilities

• The patient shall be considerate of the privacy and rights of other patients and be respectful of the doctors and team members.
• The patient shall provide complete, accurate and truthful information about present complaints, past illnesses, hospitalizations, medications and other matters pertaining to his/her health.
• The patient shall follow the treatment plan prescribed by the dental provider for either the patient or their child and actively participate in their care.
• The patient shall accept personal financial responsibility for any charges not covered by your insurance.
• The patient shall notify Acosta Dental Services at least 24 hours in advance if unable to keep scheduled appointment(s).
• The patient shall make it known to the appropriate doctor whether he/she clearly understands the course of treatment and what is expected.
• The patient shall continue care with recommended appointments and follow through with after care instructions.

Patient Financial Responsibilities

Although we file claims for you as a courtesy, your dental insurance policy is a contract between you, your employer and your insurance company. We, the dental office, are not a part to that contract.

Your treatment plan is individually tailored and is not based on your dental insurance benefits or lack of Benefits. Some dental services may not be covered in an insurance policy. Some insurance companies arbitrarily select certain services they will not cover. It is your responsibility to thoroughly understand the coverage and exceptions of your particular policy. Coverage issues can only be addressed by your employer or group plan administrator. We cannot act as a mediator with the carrier or your employer.

As such, you are responsible to pay for any deductible amount(s), your co-insurance portion and for any non-covered services. It is important to understand that you are financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and you must pay such charges in full.

All fees are valid for 60 days after the treatment plan is signed. If you have any questions regarding the treatment or financial policy, please feel free to contact: your providing doctor or our Operations Manager.