Office Policies

Please read over each item below carefully and submit the form details below. If you have any questions, please call the office at 480.948.0560.

PAYMENT

Is due at time of service, unless alternative arrangements have been made in advance.

BROKEN APPOINTMENTS

We reserve the right to charge a minimum fee of $85 for a broken appointment. A broken appointment is defined as either a “no-show” or not giving at least 24 hours notice for a cancellation.

DENTAL INSURANCE

As a courtesy, we will submit your dental claims directly to your Insurance company. Any payment from them will go directly to the subscriber.

RADIOGRAPHS

will remain the property of the practice. Duplicate x-rays will be furnished upon request for a fee of $25 per copy. If a CD is required, that fee will be $45.00.

I ATTEST TO

The fact that I am here of my own free will and personal choice, and not on behalf of any regulatory agency or investigative body.

I AUTHORIZE

the use of any records (photos, models, etc.) for educational purposes.

DISPUTE

In the event of a dispute, the parties agree to abide by binding arbitration.

PHONE CONSULTATIONS

and written reports may carry a charge (min. $150.00). Time and length dependent.

NON-REFUNDABLE

A deposit may be requested prior to scheduling lengthy appointments. The office requires 48 hours notice for cancellations for these types of appointments; full or half day Restorative, Surgery and IV Sedation Surgeries.

INSURANCE

A per incident fee of $55.00 will be assessed for insurance claim handling after initial simple submission.

MEDICARE

Is not billed by this office. This office has “Opted-Out of Medicare”.

HIPPA

I hereby acknowledge receipt of the office HIPAA Notice of Privacy Practices. It is available on our website: WWW.MILLDENTAL.COM and also in office.

CONSENT*

I agree to the office policies as stated above.

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Name

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