New Patient Office Policy Form

Mobile Dental Associates: welcomes you and we look forward to assisting you with your and/or your loved one’s dental needs. If you have any questions regarding our policies, please call our office and we will be happy to assist.

PAYMENT

Payment for all services provided by Mobile Dental Associates caregivers is expected at the time of service. We are happy to accept checks, debit cards, major credit cards(Visa, Mastercard, American Express, Discover), ACH payments, Bank Transfers, Care Credit and payments through the Zelle banking app. If paying remotely, a receipt can be emailed to the responsible party or person making the payment. Any other payment arrangements must be mutually agreeable by all parties prior to the day of treatment and will be tied to a secure payment method like ACH or Credit Card. If a decline in a patient’s health prevents the completion of a multi-visit procedure the amount due for that procedure will be prorated for the amount of services delivered and the expenses incurred. If there is a remaining unpaid prorated amount, that amount will be collected. Alternatively, if the prorated amount has been paid in full, any amount in excess of the prorated amount will be refunded.

MISSED APPOINTMENT & NO-SHOW POLICY

When our office schedules your appointment, we set aside and dedicate our chair time just for the patient. We only ask that if you must reschedule your appointment, that you please provide us with at least 24 hours’ notice. This courtesy makes it possible for us to give your reserved time slot to another patient who would be more than happy to accept. There is a charge of $75.00 per hour for not showing up or cancelling with less than 24hrs notice for scheduled appointments. *Repeated cancellations or missed appointments will result in loss of future appointment privileges. Every patient in our practice receives this unique reservation. When your appointment is made, a time is reserved, your materials are ordered, and we make special arrangements to travel to your site to be ready for your visit.

INSURANCE

Our practice does not accept Insurance as a form of payment and payment is due from the patient at the time of service unless other arrangements have been made. However, we are happy to file an insurance claim as a courtesy on the patient’s behalf. The insurance company, depending on the patient’s out-of-network benefits, may partially reimburse the patient for the services they cover. Mobile Dental Associate doctors are out-of-network providers with insurance companies, but many PPO policies may provide partial payment for some services. Please remember that we are not directly contracted with the patient’s insurance company, that contract is between the patient and the insurance company. If the patient has an HMO policy, we can still provide services but there will not be any reimbursement as HMOs typically require the patient to see an in-network provider. We will not submit claims for an HMO plan. Medicare does not cover dental services. See https://www.medicare.gov/coverage/dental-services

Consent to Electronic Communications Via Email and Text

Unencrypted email and texts are not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such communications may be misdirected, disclosed to, or intercepted by unauthorized third parties. Your signature below consents to receive email & texts from us regarding your treatment.

Your signature below indicates your acknowledgement and agreement with our Payment, Missed Appointment, and Insurance policies as well as your consent to receive electronic communications via unencrypted email and texts.