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Our Office
Dr. Juntgen
Services
New Patients
317-846-5893
317-846-5893
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Appointments
Insurance & financial policies
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Patient's Name *
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Primary insurance
Primary Insurance Information
Primary Insurance Name *
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Subscriber Name *
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Date of Birth *
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Subscriber ID Number *
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Group Number *
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Employer *
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Insurance Co. Phone Number *
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Secondary insurance
Secondary Insurance Information
Primary Insurance Name
Subscriber Name
Date of Birth
Subscriber ID Number
Group Number
Employer
Insurance Co. Phone Number
Office financial policies
Please read and confirm the following:
Financial Policies
HCPD is an in-network provider for Delta Dental Premier and Aetna PPO with Extended plans only
As a courtesy, HCPD will submit insurance claims for all patients regardless of network status
Out-of-network coverage varies greatly by plans, and patients are responsible for understanding benefits
Insurance estimations are never a guarantee of payment ; Patients are responsible for remaining charges
Costs associated with procedures not covered by insurance are due at the time of service
24 hours advanced notice is needed for appointment cancellations in order to avoid a $50/patient fee
A $35 fee will be applied to all returned checks
Sedation / hospital fees must be paid in advance to schedule and hold a date
Accounts must be in good standing (paid in full) prior to any regularly scheduled six-month cleaning appts
Payments can be made by check, cash, or credit card (Visa, MC, American Express, Discover)
Online payments are available at www.hcpdent.com
Balances over 90 days will be turned over to an external collection agency or IN State Clerk of Courts, and all charges incurred in the pursuit of the debt will be the financial responsibility of the account holder