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
like
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
by
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
my
agent in helping me obtain payment from
my insurance
company.
- I authorize use of this form on ALL
my
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
a
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
is
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.
We
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.
If
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
be
responsible for the balance in addition to collections/billing
fees.
I HAVE READ, UNDERSTAND AND AGREE TO ALL TERMS STATED ABOVE
.
.x
~
Signed (patient or parent if patient is a minor)
Date