Financial and Refund Policy

Your reservation is highly important to us, so we make a committed investment in your care. Thus, we order the materials and equipment necessary for your procedure once we book your reservation. Further, we invest in highly trained staff to provide you with the highest quality of care in the industry.

We work to ensure that you are just as committed to us as we are to you. Your reservation has been booked exclusively for you and will prevent anyone else from reserving your spot. Because of this, to book a reserved time slot, we require a reservation fee of 33% of your planned treatment. This will allow us to purchase the necessary materials and schedule trained staff and office time exclusively for you. Because this time is precious and could have been reserved for other patients who desired this slot, a cancellation fee of $50/30 minutes of reserved time will be assessed to your account if you fail to notify us at least 48 hours in advance of your scheduled appointment.

You authorize More Smiles of Beverly to bill your insurance company for all services provided. Your insurance coverage may be that some portion of the bill will remain your personal responsibility such as deductible, co-payments, or charges that are not covered by your dental insurance. You agree to make any of these payments at the time of service or as a down payment for any dental treatment that requires a deductible and/or co-pay. You understand that if your insurance does not pay or pays less than approximated, that you will be responsible to pay whatever the balance is. Your insurance coverage is a contract between you(The patient) and the insurance company to help you meet your dental expenses. It is not for More Smiles of Beverly to provide services on the basis that your insurance will always pay all charges, as coverage varies greatly. Any questions regarding your insurance benefits or coverage need to be directed to your insurance company. It is the patients/responsible party’s responsibility to provide all insurance coverage information to More Smiles of Beverly. More Smiles of Beverly will verify benefits eligibility and basic coverage prior to seeing the doctor as a complimentary service. It is the patient’s responsibility obtain insurance details. If after receiving a statement and no payment or arrangements are made within 30 days, a possible 1.5% per month service charge may be added to the account. If after 60 days no payment or arrangement has been made, then the account may be turned over to collections. When an account is referred to collections the responsible party will be liable for any collection agency fees and/or attorney fees that are incurred.

If you have dental insurance, please be aware that figures provided are ESTIMATE ONLY. Discounts may be reversed at the discretion of the dental office at any time. Coverage may be different if; your deductible has not been met, the annual maximum has been met, or if your coverage table is lower than average. Discounts are based on the volume of treatment planned per phase. Discounts may be reversed if financing is obtained for a complete phase and any part of the work in the phase is not completed for any reason. Any down payments made toward future work go towards staffing and materials needed for the procedure and are therefore non-refundable. Once treatment has begun, no refunds will be issued, including financing fees.

If a check is returned NSF there will be a $35 overdraft fee added and will no longer be able to write checks. If you refuse to provide your social security number, More Smiles of Beverly will require payment in full prior to beginning any services. Funding received through financing companies with the assistance of our website or in-office staff will have a 3-day cancellation period in which if cancellation is processed, a processing fee of 5% will be charged for administrative fees. After 3 days no cancellations of funds will be processed.

The patient is the only person allowed in the treatment room, unless given permission by staff. No cell phone use or food allowed in treatment room. Because of limited seating in waiting room, either only the patient or if patient is a minor then an accompanying adult (parent/guardian/driver) are allowed in the waiting room. Please refrain from bringing other children or adults if they do not have appointments. If a child is brought and it is the parent that has the appointment, we reserve the right to reschedule because we cannot be responsible for a child if left unattended.

I have read, understand, and agree to this office policy and sign below as my free and voluntary act.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.