As a courtesy to our patients, we will file insurance claims to the companies with whom we participate with on your behalf.  However, we need to inform you of our financial policy that states if the reimbursement is not received within forty-five (45) calendar days, from the date of treatment, the entire cost of the treatment becomes the responsibility of the patient or the person designated as the guarantor.  For this reason, we require that a credit card number be kept on file.  If you do not wish to disclose credit card information, you may pay in full prior to your treatment and we will have the insurance company issue any reimbursement directly to you.

If you are a patient who has dental insurance with a company with whom we do not participate you will be required to pay for your treatment in full prior to it being rendered.  We will provide claims forms to you to enable you to personally file for reimbursement.  It is important that you understand that any insurance policy you have is an agreement between you and the company and we cannot get involved in any dispute, conflict, interpretation, or any other insurance related problem.

All patients who subscribe to a DMO insurance plan will be required to pay any and all co-payments in full at the time of service.

If you are a patient who will be undergoing sedation dentistry, please be advised that sleep dentistry is a very new procedure that is not yet recognized for reimbursement by insurance companies.  Therefore, payment for sedation is that responsibility of the patient or guarantor and must be paid in full prior to treatment being rendered.  Although the sedation will not be covered, your insurance company will reimburse you for any benefits that they do allow under you individual plan.

____ I wish to keep my credit card number on file in order for this office to accept assignment by my insurance carrier.

          Type of credit card_______________________________
          Account number_________________________________
          Expiration Date__________________________________
          Name of card holder______________________________

____ I do not wish to keep my credit card number on file and I fully understand that I will be expected to pay in full for
          all treatment at the time of service.

APPOINTMENT POLICY
We respect the importance of your time and work very hard to schedule appointments that accommodate the busy needs of all of our patients.  In return, we ask that our patients make every effort not to change reserved dental appointments.  Broken or missed appointments create scheduling problems for other patients and out dental practice as well.  With this in mind, we reserve the right to charge for missed or broken appointments without two business days notice.

SEDATION APPOINTMENTS
The amount of time scheduled for sedation appointments is an estimate.  If the sedation appointment time runs over the amount estimated, you will not be charged for the additional time; likewise, if the sedation appointment time runs less than we estimated, a refund will not be issued.  When scheduling sedation appointments, 25% of the total amount of treatment is required at time of scheduling to reserve the appointment date and time.  If you miss your appointment or cancel without giving two business days notice, your down payment will not be refunded.

I understand and agree to the terms set forth above regarding insurance and appointment policies.

Signature___________________________________     Date___________________