Please read, sign, and submit this form a minimum of one week prior to your scheduled appointment.
Please correct the errors described below.
We require payment in full upon completion of all TMJ related appointments regardless of insurance status, or type of treatment provided. Most TMJ procedures are considered medical, but there are some procedures that may be considered dental. If you have medical and/or dental insurance, please bring your insurance cards with you to your appointment so we may verify coverage and obtain coverage benefits. If your treatment will be filed with major medical insurance please be aware that we are not a participating provider for any medical insurance company and are therefore considered out of network. Once you complete your case presentation appointment you will be given a completed medical insurance claim form and other standard information required by the insurance carrier so you can file the claim and get reimbursed. Please be aware that your out of network deductible will need to be met (if it hasn't been met already) before your insurance company will begin to reimburse you.
We require a deposit in order to reserve your lengthy initial appointment, and the amount depends on the type of initial appointment scheduled.
If you need to cancel the initial appointment, your deposit will be refunded if it is greater than 48 hours from the appointment.
If you need to cancel or reschedule your initial appointment and it is less than 48 hours from your appointment you will forfeit your entire deposit and will need to place a new deposit if you would like to reserve a new initial appointment.
TMJ Regular appointments canceled less than 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.
Emergency TMJ treatment (patients acutely locked closed or locked opened, and not a patient of record of our practice) are required to place a 50% deposit of the estimated appointment total in order to reserve an appointment.
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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