Robert S



Robert S. Nishikawa, D.D.S.

Thank you for choosing Dr. Robert Nishikawa, and for giving us the opportunity to help you meet your oral health goals. Our primary mission is to deliver the best and most comprehensive dental care available. To work towards these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Payment: All responsibility for payment for dental services for yourself and/or dependant is yours, and is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We gladly accept the following forms of payment, cash, and check, Visa, MasterCard, American Express and Discover. Please be advised we charge finance charges and billing fees on past due account balances, and penalties for checks returned for non-sufficient funds. In case of default on a payment of the account, responsibility for collection costs and attorney fees for yourself and/or dependant will be incurred.

Financing: Dental treatment is an excellent investment, and we understand that it carriers with it special cost considerations. So financial considerations are not an obstacle to obtaining the care you deserve, you may elect to apply for third party financing administered through our practice with Citi HealthCard. It offers patients a comprehensive range of plans with low monthly payments that fit comfortably into every budget. For further assistance or questions regarding the Citi HealthCard, please speak with the Patient Coordinator.

Dental Benefits: Your dental plan is a form of compensation and is a contract between you or your employer and the dental benefit plan. Although our practice is not a party to the contractual arrangement with your insurance carrier, we want to help you receive the maximum reimbursement to which you are entitled. Please understand that it is our responsibility to provide you with the treatment that best suits your needs, not to try to match your care to insurance plan limitations. Dental insurance plans do not correspond to individual patient needs, and as such; many routine and necessary dental services are not covered, even though you may need the service.

As a courtesy to you we will gladly process your insurance claims to maximize your benefits. You are still responsible for the entire balance on your account regardless of dental insurance. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the dental benefit plan. We do not accept responsibility for collecting an insurance claim, or for negotiating disputed claims. Insurance policies vary and we do not guarantee coverage, and can only estimate your coverage in good faith.

Contracted Provider: This practice is solely an in-network provider contracted with Delta Dental Premier. All charges and co-payments are the responsibility of the patient. We are required to collect the patient’s portion (deductible, co-insurance, co-pay or any other amount not covered by Delta Dental Premier) in full at the time of service. If our estimate of your portion is less than the amount determined by Delta Dental Premier, the amount billed to you will reflect this.

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Non-Contracted Provider: This practice is fee for service and is an out-of-network provider with dental benefit plans. It is the patient’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from an out-of-network provider. If your plan allows reimbursement for services from an out-of-network provider, our practice can file a claim with your dental plan and receive reimbursement directly if you “assign benefits” to us. You are responsible to pay any estimated copays, deductible, co-insurance, or any amount not covered by the dental benefit plan. You will be billed for any unpaid balance for services rendered upon receipt of payment from the dental benefit plan to our practice if the amount is different than our estimated patient portion of the bill. If you choose not to “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice in full at the time of service.

Scheduling of Appointments: We reserve the doctor and hygienist’s time on the schedule for each patient procedure, and are diligent about being on time. Because of this courtesy, when a patient cancels an appointment it impacts the overall quality of service we are able to provide. To serve all our patients in a timely manner, we may need to reschedule an appointment if a patient is 10 minutes or more late arriving to our practice. To maintain the utmost service and care, we do require 48-hour notice to reschedule an appointment. With less than 48-hour notice, a fee of $100.00 will be accessed, or deposit may be required to reserve the appointment time again. We reserve the right to charge for cancelled or missed appointments.

Authorizations: The undersigned hereby authorizes and consents for the doctor and/or associates, hygienists and assistants, as necessary to take x-rays, study models, photographs and/or any other diagnostic aids, or perform any necessary dental services deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize the doctor and/or associates, hygienists and assistants to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore I authorize and consent that doctor chooses and employ such assistance as deemed fit to provide recommended treatment. I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices and Dental Materials Fact Sheet has been made available to me, and I have been given the opportunity to ask any questions I may have regarding the Notice of Privacy Practices and Dental Materials Fact Sheet. The undersigned hereby authorizes the release of information necessary to process dental benefit claims. I hereby authorize payment directly to the doctor otherwise payable to me. I have read the above information and have been given the opportunity to ask any questions I may have, and agree to all these terms.

Print Name: ___________________________________ Date: ______________

Signature: ________________________________________________________

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