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Alexander KUTUZA D.M.D.

Specialist in Endodontics

Thank you for choosing KOS Endodontics LLC as your dental care provider.

Our office is committed to treating each patient with the same care, respect, and clinical excellence that we would want for ourselves and our families. Please understand that payment of your bill is considered as a part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.

1. Regarding Payment 

*All payment is due at the time services are rendered.

*We accept the following forms of payment: Cash, Check, Visa, MasterCard, Discover and American Express and Care Credit .

*Checks that are returned to our office from your financial   institution are subject to a $55 dollar returned check fee.

                             *A 10% discount is available to those patients who pay in full with cash.

*If account is sent to Collections a 33% Collection Fee will be added to the account.

         Per our office policy, pre-estimated fee of $200 is required to be paid for any consultation appointment regardless of insurance participation.

         All patients must pay at least 50% of our customary fees for the treatment appointment

regardless of insurance participation as a deposit fee or in full.

         If you do have insurance, we will be more than happy to submit the claim on your behalf to your insurance, and after processing of your claim by insurance and per you EOB we will issue reimbursement check for you or send you a bill by mail.

          For multi-appointment procedure a 50% deposit will be required at the start of the treatment. The remaining balance must be paid in full prior to completion of the treatment.

          For minors, the parent/guardian that accompanies the child to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre authorized before the appointment date or previous arrangement have been made with the billing receptionist.

          KOS Endodontics offers to its patients CARE CREDIT as a 3rd party lending opportunities to cover the cost of your dental procedures. Available are 6 and 12 month interest free loans, and well as longer term opportunities up to 36 months depending on the cost of the procedure being covered. Please feel free to discuss this with our financial coordinator. An application can be made in the office and usually takes less than 15 minutes to get approved.


2. Cancellation Policy

          Since we reserve time in our schedule especially for you, we feel it is most important that you keep your scheduled appointments. All appointments with our provider represent a time that we set aside for you only. When you cancel or fail to keep an appointment without proper notice you are preventing another patient with dental needs from being seen. We hope as our patient you will have the same respect for our scheduled time as we have for yours.

           All appointments missed for any reason, without a 48 hour notice ore subject to o $150.00 missed appointment fee. This fee will be automatically applied to your account each time your fail to keep your appointment regardless of reason. Depending on the circumstances that caused the missed appointment we may choose to wave this tee one time per calendar year.

          Our office must receive your notice of rescheduling or cancellation during regular business hours (8 am to 5 pm) Monday through Thursday. Notices left with our answering service after the last working day of the week (usually Thursday at 5PM) will not be considered as proper notification for a Monday cancellation. Two consecutive appointment with less than 24 hours notice will result in the inability for our office to continue to provide your dental care.


3. Late Arrival Policy

          If you are late for your appointment, we may not be able to accommodate you. If you think that you will be late, please call as soon as possible so that we may advise you if your late arrival can be accommodated, or if you will need to be rescheduled. If rescheduling becomes necessary due to excessive tardiness (more than 15 minutes) a missed appointment fee will be charged.


4. Regarding Insurance

          As a courtesy to you we will help you process all your insurance claims. If we are in network with your insurance company we will ask that you pay the deductible and co payment, which is the estimated amount not covered by your insurance company at the time we provide the services to you. We must emphasize that this is only an estimate and all charges you incur are your responsibility regardless of your insurance coverage. Insurance companies have a wide variety of rules plan Imitations, and exclusions that our office may not be aware of.

          Dental insurance usually is a benefit for the patient provided by their employer. It is a contract between you (the patient) and your insurance company. Our office is not a party to that contract. We will cooperate with the regulations and requests of your insurance company help assist in payment of your claim. However, our office will not enter into a dispute with your insurance company over any claim. Once the insurance claim has been paid, a statement will be sent to you for any remaining balance and will be due upon receipt. If your insurance company has not made a payment within 60 days, the claim will be considered denied and the unpaid balance become your responsibility and is subject to late charges and the collection process.

          We thank you for the opportunity to serve your dental health needs and welcome any questions you may have regarding your care or our policies.

6. Patient Signatures

I have read and understand the above policies concerning payment, cancellation, late arrivals and insurance payments, I understand that payment is expected when treatment is performed. I understand that I am financially responsible for any services rendered regardless of insurance policy and participation.  


Signature of Responsible Person ­­­­­­­­­­­­­­­­­­­_________________________________




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Providing treatment  to patients of the Lake Norman area and its vicinities!
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