317.873.4186

55 Brendon Way, Suite 500 - Zionsville

Office Forms

Please Download the appropriate form, print it, fill it out and bring to our office.

NEW PATIENT FORMS

(click to download)

CURRENT PATIENT FORMS

(click to download)

At Zionsville Pediatric Dentistry, we make every effort to keep down the cost of dental care.

You can help by making your payment at the time of your visit. You will be given an estimate of the approximate

total fee at the beginning of any necessary treatment and definite financial arrangements will be made with you

at that time. Services rendered on your child’s first visit must be paid that day. We have a few payment options

for your convenience:

 

Payment with cash or check the day of service

 

MasterCard, Visa

 

Insurance – We will file insurance claims as a courtesy to you at no charge. You must provide us with a current insurance card that shows mailing address and telephone number for benefit determination.

 

CareCredit – CareCredit is a flexible patient payment program, specifically designed for healthcare expenses that make it easier for your child to get the treatment or procedures they need. CareCredit lets you begin your treatment or procedure immediately-then pay for it over time with low monthly payments that easily fit into your monthly budget. Please visit www.carecredit.com or ask our front office staff for more information.

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FINANCIAL POLICY

 

PAYMENT IS DUE AT THE TIME OF SERVICE - The full balance of treatment is due at the time service is rendered.

Payment plans are not available from our office. For your convenience we accept cash, check, Care Credit, Master Card,

and Visa.

 

Assignment of Dental Insurance Benefits. Our office files insurance benefits as a courtesy. Claims unpaid by your insurance

co. after 60 days are your responsibili ty and will be due in full. All deductibles, co-payments. and non-covered fees are

due at the time of service. A CURRENT copy of your insurance card must be kept on file to utilize this service. Our office

reserves the right to discontinue and I or refuse to file claims.

 

Service Charges - A rebilling fee of $3.00 may be applied to accounts with balances unpaid within 30 days of the statement

date. A $25.00 fee will apply to all returned checks. A fee of $25.00 will be charged for appointments cancelled with less

than 24 hours notice. Our office reserves the right to pursue any other remedy by law.

 

Delinquent Accounts - Account balances that exceed 90 days may be pursued through third party collections.

All expenses incurred in the collection process will be the account holder’s responsibility. Delinquent accounts will incur

a charge of 8% interest.

 

PLEASE NOTE: We need 24 hours notice for cancellation. A cancellation fee could be charged for appointments canceled with less than 24 hours notice.

 

 

Zionsville Pediatric Dentistry,  Melissa McHenry DDS, MSD

55 Brendon Way, Suite 500  - Zionsville, IN 46077

317.873.4186