MY ASHBURN DENTIST
OFFICE POLICIES FORM
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Dear Patient,
Welcome to our office and thank you for giving us the opportunity to treat your dental needs. We want to take a moment to let you know about our office payment and appointment cancellation policies.
Office Payment Policy
Your insurance coverage has been verified and based on it, at the end of each treatment session, you will be required to pay the portion of the bill that your insurance company does not cover.
This portion, that is required at the time of your visit, is an estimate from the information that your insurance company provides to us. This estimate is fairly accurate but if there is a difference it will either be credited to your account or you will be billed.
Appointment Modification and Cancellation Policy
We appreciate your business and we understand that you have a busy schedule; therefore we will try to be as accommodating as possible. In case the pre-set appointment is in conflict with your schedule, please try to notify us of any change at least 24 hours in advance. In the event that the changes are not addressed in this timely manner or repeated requests for changes are made, your account will be charged in the amount of $85.
Thank you for choosing our office. We value you as a patient.
Sincerely,
Dr. Rusznak
Today’s Date: [datetoday]
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