----------------------------------Mill Dam DentalCare----------------------------------

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.
I 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
claim 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
problems.

All patients who subscribe to a DMO insurance plan will be required to pay 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 a sedation is the 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 your
individual plan.

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

        Type pf credit card ____________________________________________
        Account number     ____________________________________________
        Expiration date       ____________________________________________
        Name of individual on the credit card _____________________________

____ 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
accomodate the busy needs of all 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 our dental practice as well. With this in mind, we
reserve the right to charge for missed or broken appointments without two business days notice.

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

Signature_______________________ Date_______________________