Patient Information

We are in-network as a PPO provider for most insurance companies. The list that follows is not all inclusive. If you do not see your insurance provider on here, please call us to see if we are a provider.

  • Anthem: PPO
  • Anthem: 100/200/300
  • Aetna
  • Ameritas
  • Cigna
  • Connection Dental
  • Delta: PREMIER&PPO
  • GEHA
  • Humana
  • Metlife
  • United Health Care
  • Superior Dental

If you do have dental insurance and have a benefits card please bring it with you to your dental appointments.


We accept Visa, MasterCard, American Express, Discover or check.

We also offer CareCredit.

Payment is due at the time service is rendered unless other arrangements have been made in advance.


Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.



  • Payment Policy:  Our office is a fee for service office, meaning we politely ask you for your portion of the visit as payment at the time services are rendered. For your convenience, we accept:
  • No Cash Accepted!
  • Credit Card:  Visa, Master Card, Discover, American Express
  • Personal Check
  • Care Credit
  • Dental Benefits



*Payment in full at time of appointment by check, cash, or credit card receives a 5% courtesy, on treatment exceeding $1000.00.

*Senior Citizen courtesy of 5% with Golden Card at time of service.


  • The adult, parent(s), or legal guardian accompanying a minor child is responsible for the family's portion, not covered by any Dental Benefits you may have at the time services are rendered.
  • For unaccompanied minors, non-emergency treatment will be denied unless arrangements for payment on a pre-authorized credit card, cash, or check are made prior to the appointment date and time.
  • Minors with two separated parents: When two parents are each responsible for one half of the cost of the children's dental care, the parent who brings in the child is responsible for paying the co-payment or full fee. They will also be responsible for collecting payment from the other parent.
  • Emergency Patients: There is to be one method of payment ONLY for emergency treatment of a patient new to the practice. Patients must pay at the time of service until they have been established as an existing participating patient and then payment policies will apply.
  • If your account balance is turned over to our collection agency, you agree to paying an additional 30% of the unpaid balance. This additional amount is applied to cover collection agency fees. We charge a $25 returned check fee.
  • We try our very best to accurately estimate your portion on the date of service based on the information given to us by your insurance carrier. However, sometimes there is a need to send you a statement, which will be mailed to you the same day payment is received from your insurance company for you visit.
  • Our courtesy service to you includes electronic filing your insurance within 24 hours of your appointment so that benefits may be paid directly to our office, researching your plan to advise you of benefits available to you and following the American Dental Association guidelines for coding and filing insurance claims.
  • Our expectation of you as the owner of the policy is to make payment in full of fees or co-payments not covered by your insurance plan at the time services are rendered. We also ask that you understand that the policy belongs to you and we have no leverage to obtain payment from your insurance company. With that, we ask that you take responsibility for payment of your visit should your insurance company not pay within 75 days of your appointment date. In order to avoid this situation, we ask that you keep our office informed of any changes in your insurance coverage or employment.
  • Every dental insurance policy has a maximum benefit, which we are able to track for services rendered in our office. If you have received care by another office, we cannot be responsible for calculating your remaining benefits accurately. You may call your insurance company to receive an updated amount after services have been paid to all offices involved.



A $75 fee per hour scheduled will be placed on account

for patients who have a broken appointment, a no-show or short notice (less than 48 hours) cancellation for appointments Monday through Friday 9:00-4:00. NOTE: All cancellation fees must be paid prior to scheduling another appointment.


The treatment that is planned for you is specific to you. It is important for you to keep the scheduled dates and times to properly complete your treatment.A broken appointment is a loss to three people---the patient who missed the valuable time, the patient who could have taken the valuable time, and the doctor who was fully staffed and prepared for the appointment.


I hereby authorize Dr. Kimberly Michalak to release to my insurance company, information acquired during my dental care. I hereby authorize benefits to be paid directly to Dr. Kimberly Michalak. I understand I am responsible for any unpaid balances. I agree to be responsible for dental services not paid by my dental benefit plan. I have read and agree to this financial protocol.


Thank you for understanding our financial policy and please feel free to ask any questions or voice any concerns you may have regarding it.


ACKNOWLEDGEMENT OF RECEIPT: I acknowledge that I received a copy of the Hayden Run Dentistry Financial Policy.


Patient Signature _________________________

DATE ______________


We have digital radiography at Hayden Run Dentistry. Digital X-rays are one of the newest X-ray techniques around and can reduce patient radiation exposure by 80-90%. We even have the ability to take bite wing images outside of the mouth! Great for patients that have a profound gag reflex or find the bite wing tabs to be uncomfortable.


Dr. Michalak and the entire team follow infection control procedures set by the Occupational Safety & Health Administration, the EPA, and CDC. We are up to date on training and have a yearly OSHA review to ensure our safety and the safety of our patients.

Dr. Michalak worked at a sterilization monitoring service for three years during college and knows the importance of frequent monitoring.


We sterilize all reusable equipment. We surface disinfect between all patients. We use an autoclave that is designed to kill bacteria and viruses through a combination of steam, heat and pressure. We monitor our sterilization weekly as mandated by law using the Sterlization Monitoring Service at OSU. We use universal precautions such as gloves, masks, and eyewear.


Hayden Run Dentistry-HIPAA - Records Release

We are using a new feature of our existing appointment confirmation system. You will receive a text and/or email for online paperwork. If you are a new patient you will receive a New Patient Packet and if you are an existing patient you will receive a Recare Update Packet. Please bare with us! If you are having any mobile/technical issues do not hesitate to call. You are more than welcome to arrive early to your appointment to fill out Paper Paperwork if you prefer this method!


Existing Patients Print Outs:

Medical History


New Patients Print Outs:

Financial Policy
Hippa Consent
Hippa Notice
Medical History
  •   Office Hours

    • MON 9:30am-6pm
    • TUE 9:30am-6pm
    • THU 9am-5pm
    • FRI 9am-4pm
  • Why Hayden Run Dentistry?

    • High quality, proven materials
    • Latest technology
    • Exceptional attention to detail
    • Outstanding Service


    • © 2023. Hayden Run Dentistry. All Rights Reserved.

Call Now Button