It is the patient's responsibility to call the office or bring the current dental insurance information to the appointment. We will do our best to verify your insurance and submit the claims electronically; however, it is the patient's responsibility to pay for any services that are not covered by the insurance company. I agree to be responsible for all charges for dental services and materials that are not covered by my dental benefit plan.

For patients that choose to pay privately or have procedures completed that are not covered by insurance, we offer a 5% savings provided payment is received in full on the day treatment is started. A copy of the treatment plan will be provided to ensure full disclosure of all costs involved in treatment. I understand payment is due the day of service.

Although a 24 hour notice is required to cancel dental appointments, a 48 hour notice is preferred. We understand that there are certain circumstances that are out of your control. 66th Street dental's office provides a courtesy reminder to patients for all appointments two days prior to the appointment. If we are unable to reach you in person, please call us back to confirm that you will be able to keep your appointment. Upon the first failed appointment, a verbal reminder of our policy will be given. A mailing of the Failed Appointment Policy will be sent upon a second failed appointment. Should a third failed appointment occur, a dismissal letter will be mailed informing the patient that he or she may only be seen 15 days after the letter was mailed for an emergency basis only. At this time, the patient who has failed three times will be expected to find a new dentist. When making dental appointments, please inform us of the best way to reach you to confirm the appointment. I understand 66th Street dental's failed appointment policy.

10/2014