Bellmore Family Dental Office Policies

Signature On File Form

Thank you for

selecting

Bellmore

Family

Dental as your personal dental team. To promote a long-term

mutually satisfying

relationship,

we would

to explain our office policies

regarding

insurance,

missed

appointments,

lab required

services,

treatment and payment. PLEASE read and ask

any

questions before treatment is rendered. Submission to treatment implies your consent to terms of this

agreement.

*Insurance:

We accept most insurance plans as full or partial payment. If you do not

fully

understand your

coverage,

be sure to inquire about any out-of-pocket expenses prior to treatment.

Any

estimated fees given

our office are considered

guidelines. Your insurance company will make the final decision when your

claim is processed and at that time your account may reflect changes accordingly.

- I understand and agree that all insurance deductibles and any incurred

expenses

not covered by the

insurance carrier must be paid for at the time of

services.

- I understand that my insurance is an agreement between my insurance and me. I understand that I am

responsible for the payment of any and all charges incurred as a result of this or any subsequent office

visit( s). I also understand and agree to accept

responsibility

for payment of any and all claims should my

insurance carrier deny all or part of a claim.

- I

authorize Bellmore Family

Dental to act as

agent in helping me obtain payment from

my insurance

company.

- I authorize use of this form on ALL

insurance submissions.

- I permit a

copy

oftbis authorization to be used in place of the

original.

*Missed Appointments:

When you schedule an appointment we put aside a specific

amount of

time for

you with that provider. If you are unable to attend your scheduled appointment we require

minimum of24

hrs.

notice. When the required notice is not

given,

a fee of$50 per half hr. scheduled will be charged to

your account. (Insurance does not

pay

for broken

appointments.)

*Treatment:

Services that require lab work specifically fitted to your mouth (such as

crowns, bridges,

dentures, etc). are time sensitive. Being in a temporary appliance beyond what

advised by the doctor may

result in additional treatment being needed (e.g.,

extraction,

root canal, removal of recurrent decay.)

Failures by the patient to return for the delivery of the final restorations as advised are subject to doctors'

time and lab fee charges.

- I give permission for my dentist and his/her clinical team to take any necessary

x-rays, photos,

or study models

to enable complete diagnosis and treatment.

*Payment:

All

out-of-pocket

expenses are due at the time services are

rendered.

accept cash,

all major

credit cards and personal checks for established

patients.

We offer other payment options for extensive

dental work. Arrangements for alternate payment methods must be discussed prior to receiving services.

- Returned

checks: There is a $30 fee for returned checks.

- Collection: Since payment is due at time of

service,

there are rare occasions your account will have an

unpaid balance.

this situation arises we will send one bill as an attempt to collect the owed debt.

Failure to pay will result in collections

proceedings.

If the account is sent to collections you

will

responsible for the balance in addition to collections/billing

fees.

I HAVE READ, UNDERSTAND AND AGREE TO ALL TERMS STATED ABOVE

Signed (patient or parent if patient is a minor)

Date

Bellmore Family Dental Office Policies - Signature On File Form

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