Appointments: Appointment times are reserved for you. We make every effort to reach you to remind you of your appointment, however, your appointment is your responsibility. We do requirea24-hour notice prior to canceling an appointment.
Payments: As a condition of your treatment by our office, payment is due in full at the time services are rendered. We are a fee-for-service office and therefore depend on reimbursement from patients for the cost incurred in their care.
Treatment Plan Estimates: Treatment plan estimates are just that. We will make
every attempt to plan accurately, but unanticipated situations do arise and can effect previously planned treatment. Patients will be notified of applicable fees before services are rendered. Afee estimate is effective for 90 days.
Patient Permission: In consideration for the professional services rendered to me, or at my request, by Dr. Smith, I agree to pay the fee for said services to Dr.Smith or his assignee at the time services are rendered. I grant my permission to Dr. Smith, or his assignee, to telephone me at home or my place of employment to discuss matters related to this form.
Health Insurance Portability and Accountability ACT (HIPPA)
I acknowledge that I have read a copy of this office's Notice of Privacy Practices.