USUAL AND CUSTOMARY RATE (UCR)
Our practice is committed to providing the best treatment possible for our patients. Our relationship is with you, not your insurance carrier. While the filing of insurance claims is a courtesy we provide to our patients, all charges are your responsibility from the date of service that are rendered. Keep in mind, that the rates paid by your insurance carrier are determined by the insurance carrier and your employer and, in some situations, have no bearing on the real usual and customary rates charged in the local areas.
Although your policy may state you have 100 percent coverage on either preventive or basic services, be aware that you may still have an out-of-pocket cost, which may include your annual deductible and may have an annual maximum paid. Any information our office gives you regarding your insurance coverage is an estimate. We make these estimates based on information available to us. We are not responsible for any decisions regarding payment that the insurance carrier makes.
PAYMENT IS DUE AT TIME OF SERVICE: Payment Options: Cash, Check, MasterCard/Visa/Care Credit.
PATIENTS WITH INSURANCE: The PATIENT is responsible for the ESTIMATED non-covered portion, procedures and/or deductibles at the time of the services.
PARENTS NOT ACCOMPANYING THEIR CHILD to an appointment must make PRIOR arrangements for payment.
DIVORCES: Both partners are responsible for debts incurred up to the dare of the divorce decree. If a dispute over payment arises after the divorce is final, we must have a copy of the divorce decree. The parent who requests treatment for a child is responsible for balance of services rendered for your child.
OFFICE POLICY
APPOINTMENT FAILURES AND CANCELLATIONS:
If a patient fails to show for their appointment more than twice or if they cancel their appointment less than 24 hours’ notice consecutively you will be dismissed from Magical Smiles and a fee may be charged for all appointment failures and cancellations.
In addition, we are a family-oriented office and we want to emphasize and remind everyone the importance of practicing proper manners while at Magical Smiles Family Dentistry. We have ZERO tolerance policy for Rudeness or Misconduct toward the staff. If a patient, caregiver or significant other exhibits a lack of courtesy towards a team member, immediate and permanent dismissal from Magical Smiles Family Dentistry will be given.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.