BROKEN APPOINTMENT/LATE PATIENT POLICY

Reserved appointment time in any dental office is limited and valuable. It is extremely important

that all patients honor their reserved dental appointments. Failure to do so deprives our other

patients from receiving needed dental care in a timely fashion.

Those who fail to keep scheduled appointments should not penalize the Dentist, our staff, and

mainly our other patients. Our dental policy stipulates that failure to give sufficient notice to keep a

scheduled appointment (1 working day notice) will result in a fee being charged. That charge is in

accordance with our dental office’s broken appointment policy for all of our patients. The patient is

responsible for payment of the charge.

** If you have an e-mail address registered with our office you will be sent an e-mail reminder and

you can confirm online. Otherwise, our staff will call 1 to 2 days prior to our scheduled appointment

to confirm with you. We will attempt all numbers that you have provided us. If we have to leave a

message on your machine or cell phone, it is your responsibility to call us back to confirm your

appointment. Remember that we are closed early on Fridays so cancellations of Monday

appointments must be called into us on Friday before 2pm.

The usual and customary fee for broken appointments is $35.00

Patients who arrive more that 15 minutes late to their scheduled appointment time may be asked

to reschedule as a courtesy to our other scheduled patients. ______ (initial here)

_________________________________ __________________

Patient, Parent, Guardian Signature Date

CANTON MARKETPLACE DENTISTRY

PATIENT FINANCIAL POLICY

As a service to our patients, CANTON MARKETPLACE DENTISTRY is more than happy to directly bill your insurance for your services rendered, but it is our policy that the patient is ultimately responsible for payment of services received from CANTON MARKETPLACE DENTISTRY.

Your insurance policy is a contract between you and your insurance company. If your insurance does not pay the claim within 30 days mandated by the Georgia Law we will look to you for payment.

As the patient, you are responsible for understanding your insurance coverage in relation to covered services and you are responsible for providing CANTON MARKETPLACE DENTISTRY with the most current insurance information. Patients who do not bring their insurance card for their appointment will be required to pay for services rendered at the time of service. Once the insurance is billed and payment has been received, CANTON MARKETPLACE DENTISTRY will refund any credits due to thepatient.

As part of our contract wtih your insurance company, we are required to collect your co-pay at each appointment without exception. This is not a policy credited by us, but is instead mandated by GeorgiaLaw.

All dental plans are not the same and do not cover the same services. In the event your dental plan determines a service to be "not covered", or you do not have an authorization, you will be responsible for the complete amount. We will attempt to verify benefits for some specialized services; however, thisis not a guarantee of payment and you remain responsible for charges of any service rendered. All patients are encouraged to contact their plans for clarification of benefits prior to your appointment.

You will receive a statement of any amount owed after your insurance pays. The balance is due within 15 days. If payment is not received in full and it is necessary to send an additional statement, there will be a $10.00 billing fee added for each additional statement you receive. Please understand that repeated efforts to contact patients for payments owed is both time consuming and costly.

Past due account are subject to collection proceedings. All fees including, but not limited to collection, fees, attorney fees shall become your responsibilty in addition to the balance due this office.

Our goal is to provide you with exceptional care and service. We are committed to helping your fulfill your financial commitment to CANTON MARKETPLACE DENTISTRY. If you have any questions or concerns regarding our financial policy our Office Manager will be happy to discuss them with you.

Signed:_______________________________________________ Date:___________________________ (Patient or person legally authorized to consent for patient)

Printed Name:_________________________________________