Insurance AuthorizationI certify that I, and/or my dependent(s), have insurance coverage with the Insurance Company(ies) provided at intake and assign directly to Stella Dental or its affiliates, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Stella Dental or its affiliates may use my health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Payment ArrangementsPayment is expected the day service is rendered.
- We accept Visa, MasterCard, Discover, American Express.
- We offer payment plans and interest-free financing for approved patients through Lending Point
- We accept most major PPO plans towards payment. Your estimated out of pocket responsibility is due at time of your treatment.
- Refunds are issued by check. Please allow 5-7 business days after insurance payment for credits to be issued as a refund.
Disclaimer or Warranty and Limitation of LiabilityIf you are dissatisfied with your service, you must file a customer service issue with Stella Dental or its affiliates within 24 hours of your visit. Any customer service issue will be subject to mediation between the patient and Stella Dental or its affiliates.
You hereby agree to release Stella Dental, its affiliates and third-party service providers, and each of their respective directors, officers, employees, and agents from any and all claims, demands and damages (actual and consequential) of every kind and nature, known and unknown, suspected and unsuspected, disclosed and undisclosed ("claims"), arising out of or in any way connected with your use of this site and its services. If you are a California resident, you waive California civil code section 1542, which states, in part: a general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.
This document provides a summary of how health care information about you may be used and disclosed and how you can obtain access to this information.
We understand that information about you and your health is personal. We are committed to protecting your health information. It is our policy that the privacy of your protected health information (PHI) not be compromised while still allowing necessary access to assure that the health care you receive is appropriate and of the highest possible quality.
We pledge to you that we will protect the confidentiality of information provided to us. Your information will be used in the following manner, known as Treatment, Payment, and Healthcare Operations (TPO):
- To provide dental treatment and/or services.
- To facilitate payment by third party payers, when appropriate, for health care treatment you receive.
- To facilitate the mechanisms which allow the operation of our facility.
You have the following rights regarding the medical information we maintain about you:
- Access, upon request, to information that may be used to make decisions about your care.
- To request restrictions or limitations on the PHI we disclose about you for treatment, payment or health operations. While we are not required to agree to your request, if we do agree, we will comply with the restrictions unless the information is needed to provide emergency treatment.
- To request that we amend the PHI we maintain about you if you believe that the information we have about you is incorrect or incomplete.
- To request an accounting of disclosures we have made for uses other than our own.
- To request confidential communications; i.e., that we communicate with you in a certain manner or at a certain location.
- To receive a paper copy of this notice.
Stella Dental or its affiliates will not use or disclose your PHI without your prior authorization. You can later revoke that authorization in writing to allow any future use and disclosure. The authorization will be obtained from you by Stella Dental or its affiliates.
Should you believe that your privacy rights have been violated, you may file a complaint with this facility or with the State oversight department; all complaints must be submitted in writing. You will not be penalized for filing a complaint.