The Exchange Dental Group strives to be punctual, therefore we ask that our patients keep their appointments and also arrive on time. If a patient must cancel
an appointment, we require at least 24 hours notice, with the exception of Sunday appointments which must be cancelled by Friday 12pm the latest. There will
be a $100 charge for EACH appointment missed or not cancelled 24 hours prior to the scheduled time, or by Friday 12pm respectively.
The Exchange Dental Group will make every effort possible to assist our patients with their insurance, however please keep in mind that dental insurance is
a contract between the insurance company and the patient, not the dental provider. It is up to the patient to fully understand his/her benefits to ensure the
appropriate disbursement of benefits under the terms of each individual plan.
It is the patient's responsibility to notify The Exchange Dental Group should there be any change in the insurance plan. It is also the patient's responsibility to
notify us of any dental procedures that have been done in other dental offices that may reduce the insurance benefits available for the year.
As a courtesy to our patients, The Exchange Dental Group provides a treatment plan of which includes an estimate of the recommended treatment, the
expected coverage from the dental coverage as well as the patient's copayment respectively. Benefits quoted to you are only an estimate provided by the
insurance company and not a guarantee of payment or eligibility at the time the services are performed. The Exchange Dental Group will submit claims and
accept the assignment of benefits from the insurance company on behalf of the patient provided the patient pays their co-payment for each visit, due at the
time of treatment, unless prior arrangements have been made, as we offer various financial programs to assist our patients with affordable monthly payments.
In the event that the claim is not paid by the insurance company within 30 days, the balance becomes the patient's responsibility and is due immediately.
Any balances that remain unpaid after 90 days will be turned over to collections.
* Please note that a $25 returned check fee will be added to the balance for all returned checks.
A misunderstanding can be an obstacle in establishing a successful relationship. If at any time you have a question regarding treatment, fee or service,
please discuss it with us promptly and openly.
I, the undersigned, have read and understood the above and I consent to all the terms and conditions set forth in this agreement.
Signature of Dentist
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