Financial Policy Form

Our office is committed to providing you with the greatest possible dental care. We want to make certain that our financial policies are clear and understood by you. If you have dental insurance, we will make a good faith estimate of your benefits and defer billing you for that amount up to 45 days. We will file the appropriate claim forms with your insurance company, provided that you provide us with your personal information including social security number and date of birth. Please keep in mind that dental coverage is meant to be a partial reimbursement for your dental care.

If your insurer denies coverage for any or all procedures; if we do not receive payment within 30 days from the date services are rendered, the balance will then become due and payable by you (your guardian, or person financially responsible for your account). We must emphasize that as dental care providers, our relationship is between you, not your insurance company. Your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Most dental plans have limitations and restrictions, we cannot, therefore, guarantee your insurance company will pay.

Your payment is due when services are rendered, no exceptions, unless prior financial arrangements have been made the financial coordinator of Hedyeh Atashbar, D.D.S., L.L.C. We accept Visa, MasterCard, Discover, cash and/or personal checks (in-state only and between the range $15.00 - $999.00). Check and Credit card payments are a minimum of $15.00. Lab related services such as crown and bridge, partials and full dentures require 50% at the preparation date and 50% prior to the insertion of the prosthesis.

I acknowledge my responsibility for payment of services rendered by Hedy Atashbar, D.D.S, L.L.C. in accordance with Hedy Atashbar, D.D.S, L.L.C. fees and terms. I understand my responsibility is not modified by whether any third party (insurance) pays for all, part or none of the charges. If the balance is not paid within 30 days of the billed statement, your account will become delinquent and will either be turned over to a third-party collection agency and/or a Small Claims Case will be filed in the District Court of Maryland in Montgomery County. If this becomes necessary, additional fees from the third-party collection agency will be added to cover handling charges. An 18% APR finance charge is automatically tabulated into accounts 60 days or older. Our fee for Returned Checks is $35.00.

This agreement becomes effective the date the patient begins their first visit with Hedy Atashbar D.D.S., L.L.C.

I have been informed of and agree to the policies of Hedy Atashbar D.D.S., L.L.C. as stated above.

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.

Cancellation/Late Policy

At Hedy Atashbar D.D.S., L.L.C., we recognize that in today’s busy world, adhering to a schedule is important in order to maximize time and meet the demands of daily life. With this in mind, we have developed a cancellation policy that is fair to both our patients and our practice. We are committed to seeing our patients on time and respecting their time. Late cancellations (less than 48 hours notice) failed appointments, and late arrivals are disruptive to our schedule and other patients. In order to maintain our schedule, we request 48 hours notice for cancellations or rescheduling of appointments. In the instance of a late cancellation (less than 48 hours notice) or a failed appointment there will be a $55.00 charge per hour of scheduled appointment.

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.