Financial:

1. We will be happy to bill your insurance for you. We will need all pertinent information, such as group #'s, social security #'s, birth dates, employer, etc. We also need to know if any information ever changes.
2. You are responsible for paying your estimated co-payment at the time of service and any amounts not paid by your insurance after billing is complete.
3. You need to keep a record of your insurance payments and inform us when you reach, or are near to reaching your yearly allowance. Your plan booklet will explain how much you get to spend each year per person.
4. For non-insured patients payment is due each appointment that treatment is received, unless financing has been arranged.
5. For your convenience we offer several types of payments:
   • Cash/Check
   • Mastercard /Visa
   • Interest free financing for up to 12 months through CareCredit or Wells Fargo. (Also low interest for plans over 12 months)
6. Upon request, we will give you a written estimate of your needed payment, or co-payment amounts.

Appointment Policy:

1. We require at least 24 hours notice if you need to change your appointment. Please call our office at the earliest time you know you will not make it to your visit.
2. If you schedule an early a.m. appointment, please do not cancel. It is veiy difficult to fill these early morning openings if you do not show up.
3. Please arrive at least 5 minutes early to your appointment so we may update any information.
4. If two or more appointments are missed without proper notice a fee up to $75.00 may be charged to your account. We understand 24 hours notice may not always be possible. However, we must get a call before the appointment time.
5. If you have scheduled more than one appointment, and miss the first of those without notice, the patients following visits will not be saved until the next visit is kept.
6. We make eveiy effort to run on time. If you are more than 15 minutes late for your appointment alert the front desk. They will do whatever is possible to get you seen.
7. Parent(s)/Guardian(s) must accompany minors under 18 years of age. A permission slip may be signed, but must be for each visit.

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
• Obtain payment from third-party payers for my health care services
• Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment of health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.