Office Fees & Policy


Financial Policy


We accept all major credit cards, valid checks and cash. We participate with the CareCredit finance program, which allows you to make payments over a six month period at no interest. For more information you may go to or call 1-800-365-8295.

Office Policy

As a courtesy, we will file your dental insurance claim for you.  We are a Delta Dental,  MetLife, Humana, Principal, Ameritas, Assurant, Aetna, Guardian, Health Partners, and  United Concordia provider.

Prior to your appointment, we suggest you contact your dental insurance to get benefit and eligibility information for your endodontic appointment. The benefit information should include: in-network or out-of-network endodontic coverage, deductible, maximum dental benefit amount (per plan year or calendar year) as well as benefits used-to-date. The patient portion is only an estimate. Please keep in mind insurance companies routinely indicate that coverage verification does not guarantee payment. Pre-authorizations for treatment are not filed automatically with insurance.

For all non-assigned insurance claims, we will collect payment in full from patient at the time of appointment. We will file the insurance claim on your behalf since payment will be issued directly to the insured. We will collect payment in full from patient at the time of appointment for all 3rd party claims (ie: work comp, accident, injury, sports, legal). If for any reason the insurance payment is sent to the patient, the insured or representative (instead of our office), you will have 14 calendar days to provide payment in full.

After the insurance payment has been applied to your account a statement will be mailed and the balance is due immediately. We reserve the right to apply the balance to your credit card. For your convenience, you may contact our office and pay by phone using a credit card. If there is a credit on your account a refund will be issued.

Finance Charge: A finance charge will be imposed on each item of your account which has not been paid within thirty (30) days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one percent (1%) per month or an ANNUAL PERCENTAGE RATE of eighteen (18%) percent. The finance charge on your account is computed by applying the periodic rate (1%) to the "overdue balance" of your account. The "overdue balance" of your account is calculate by taking the balance owed thirty (30) days ago, and then subtracting any payments or credit applied to the account during that time. The minimum finance charge is $.50.

Accounts that are 90 days delinquent will be turned over to our collection agency. All additional fees will be your responsibility.


NOTE: If your insurance company does not reimburse us after 2 submissions (60 days), you will be responsible for the remainder of the balance since we were unable to collect from them.

Privacy Policy


We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify afftected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 9/23/2013, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records my be entitiled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment:  We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment:    We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.


Healthcare Operations:  We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care:   We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patent representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief:   We may use or disclose your health information to assist in disaster relief efforts.

Public Health Activities:   We may disclose your health information for public health activities, including disclosures to: Prevent or control disease, injury or disability; Report child abuse or neglect; Report reactions to medications or problems with products or devices; Notify a person who may have been exposed to a disease or condiditon; or Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

Required by Law:  We may use or disclose your health information when we are required to do so by law.

National Security:  We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS:   We will disclose your health information to the Secretary of the U.S. Deptartment of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker's Compensation:  We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Law Enforcement:  We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry our their duties.

Fundraising:  Our office will not use your information for any fundraising activities. 

Other Uses and Disclosures of PHI: Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.


Access:  You have the right to look at or get copies of your health information, with limited exceptions.  You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.

If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requriements of applicable law.

Disclosure Accounting:  With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and  regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost based fee for responding to the additional requests.

Restriction:  You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written requst must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication:  You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or location you requested we may contact you using the information we have.

Amendment:  You have the right to request that we amend your health information.  Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice:  If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. 


If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services. 

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Information:  Tri-State Endodontics   Attn:  Michael Homer DMD.   Address: 3500 South Kiwanis Avenue, Suite #100, Sioux Falls, SD  57105.  Phone # (605) 336-3446   Fax # (605) 373-9269.