Please read, sign, and submit this form a minimum of one week prior to your scheduled appointment.
Please correct the errors described below.
We accept most Dental Insurance plans but are notparticipating providers for any insurance company. If you have dental insurance this means that most of the procedures will be reimbursed at a certain percentage of a UCR fee that your insurance company sets. This is not a percentage of our fees. As a result there will almost always be an amount that you would owe after insurance pays. It is our policy that you pay your estimated portion that will not be covered by insurance at the time the service is provided. Insurance companies do not give out UCR fee information to us therefore the amount we collect from you at each appointment is truly just an estimate. Only once we receive an insurance payment for your appointment will we know if there is still a balance due. If a balance exists, a bill will be sent to you and payment will be expected within 15 days of receiving the bill. Understand that you are responsible for paying the balance of your account if the insurance claim has not been paid to our office within 2 months of the date of treatment. Please remember to bring your dental insurance card with you to your first appointment. If you do not have dental insurance we require payment in full at the time services are provided. We accept cash, checks, Visa, MasterCard, and Discover card.
We require 48 hours notice for canceling appointments.
Appointments canceled under 48 hours and no shows for appointments are subject to a penalty fee of $50.00 per hour of appointment time.
Please be aware that the cancellation of a Monday appointment must occur by 2 pm the Thursday prior in order to avoid an inadequate cancellation fee.
Late arrivals to appointments may be rescheduled and subject to a fee.
Excessive inadequate cancellation and no shows will require a deposit to secure future appointments.
We truly value our relationships with our patients. Like any relationship, communication is vital to avoid misunderstandings and hard feelings. This document is the first step in developing an open and honest relationship. If there is ever anything that you don’t understand whether related to your treatment or your account with us, please don’t hesitate to ask questions. We will do our very best to help clarify things for you. Again, thank you for choosing our practice. We look forward to working with you to achieve improved oral and cranio-mandibular health.
Sincerely, Dr. Steven Gold and Staff
-WE WILL ASK YOU TO SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND OUR POLICIES.
have read the above information and policies of the office of New Garden TMJ & Dentistry. I have had the opportunity to ask questions, received satisfactory answers to my questions, and fully understand and intend to abide by the above policies.
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