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.
Thus, 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, in order to book a reserved time slot, we require a reservation fee of 50% 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.
I authorize More Smiles of Beverly to bill my insurance company for all services provided. My insurance coverage may be that some portion of the bill will remain my personal responsibility such as a deductible, co-payments, or charges that are not covered by my dental insurance. I 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. I understand that if my insurance does not pay or pays less than approximated that I will be responsible to pay whatever the balance is. My insurance coverage is a contract between me and the insurance company to help me meet my dental expenses. It is not for More Smiles of Beverly to provide services on the basis that my insurance will always pay all charges, as coverage varies greatly. Any questions regarding my insurance benefits or coverage needs to be directed to my insurance company. It is the patient’s/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 appointment as a complimentary service. It is the patient’s responsibility to obtain insurance details. If after receiving a statement and no payment or arrangements are made within 30 days a 1.5% per month service charge will be added to the account. If after 60 days no payment or arrangement has been made then the account will be turned over to collections. When an account is referred to collections he responsible party will be liable for any collection agency fees and/or attorney fees that are incurred.
If a check is returned NSF there will be a $35 overdraft fee added and I will no longer be able to write checks. If I refuse to provide my social security number, More Smiles of Beverly will require payment in full prior to beginning work. Funding received through financial companies with the assistance of our website or in office staff will have a 3 day cancellation period in which if a cancellation is processed, a processing fee of 5% will be charged for administrative fees. After 3 days no cancellations or refunds will be processed.
The patient is the only person allowed in the treatment room, unless given permission by the staff. No cell phone use or food allowed in the treatment room. Because of limited seating in the waiting room, either only the patient or if the patient is a minor then an accompanying adult (parent/guardian/driver) is 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.
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. Down payments made toward future work go towards staffing and materials needed for the procedure and are therefore nonrefundable.
I have read, understand, and agree to this office policy and sign below as my free and voluntary act.