Assignment and Release
I, the undersigned, assign directly Mirage Family Dentistry all benefits, if any, otherwise payable by me for services rendered. I understand that I am financially responsible for all charges, whether or not they are paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.
Patient Agreement and Financial Policy
I hereby agree to be responsible for the costs of care, all of which must be paid upfront prior to scheduling any treatment appointments to avoid increased office fees resulting from unpaid fees for services provided by Mirage Family Dentistry and the dental team for myself or my dependent(s). These include any deductibles and amounts not covered by insurance. I also understand that it is my responsibility to be aware of any limitations and benefits of my insurance policy. Payment to this office is my responsibility, and I am aware that if the insurance company does not reimburse the doctor, I will be responsible for the total amount(s).
I understand that there will be a $30 charge to all accounts in which a check payment is returned.
I understand that because appointments are not double-booked, I must provide notice of cancellation at least seven days before my scheduled appointment time (Please exclude our closed hours.) Any unconfirmed appointments will be removed from our system without any notice. A $100 cancellation fee/ appointment hour may apply if I do not provide notice of cancellation at least 48 business hours before my scheduled appointment time.
We kindly ask that upon receiving your appointment reminder call, email, or text message, you confirm by one of these three methods. This allows us to guarantee your appointment time is still available as scheduled and that no changes have occurred.
We make every effort to schedule appointments that are most convenient for you, and that fits your personal schedule. Because we do not schedule several patients simultaneously, all appointments are reserved exclusively for you. In return, we ask that you try to keep the dental appointment you reserved the same.
Regrettably, this office can no longer assume the responsibility of knowing each and every individual insurance plan or exactly what our relationship is with them on any given day. There are hundreds of insurance plans on the market at this time. We can no longer afford to assume the financial liability this imposes on us and remain in the dental business.
We, therefore, encourage our patients to be familiar with their insurance coverage and limitations on an ongoing basis. DO NOT HESITATE TO CALL YOUR INSURANCE COMPANY. YOU HAVE EVERY RIGHT TO RECEIVE AN ORAL OR WRITTEN REPLY.
I understand that payment in full is due at the time of service for any treatment. I understand that if there is a balance after insurance pays, I am responsible for that balance. After 60 days, any unpaid balance will incur a $10 billing fee. I understand that failure to pay amounts due to this office will result in my account being placed with a collection agency. In the event that my account is further referred to an attorney, I agree to pay all collection and attorney fees.