Thank you for choosing us as your Dental Care Provider. We are committed to your treatment being
successful. Please understand that payment of your bill is considered part of your treatment. All
patients must read and sign this form prior to seeing the doctor.
DENTAL INSURANCE: Our office will gladly work with you to help get the maximum benefit available to
you. Most dental insurance plans do not cover 100% of your treatment cost. Therefore, you will be
expected to pay your deductible and your estimated co-payment on the day that the services are
rendered. We will gladly file your insurance claim as a courtesy. Many variables exist from carrier to
carrier (i.e., restrictions): therefore, we cannot guarantee any estimated charges. Your policy and
benefits are an agreement between you and the insurance company so ultimately you are responsible
for all charges. Please know that we will do everything possible to see that you receive the full benefits
from your insurance company. If for some reason your insurance company has not paid their estimated
portion within 60 days from the start of treatment, you are responsible for payment in full at that time.
Treatment could be altered if your dental needs change. The patient will be notified of any change(s) in
treatment. We will gladly file all dental claims for any given treatment, but we are not party to any
insurance programs or contracts. The balance is YOUR RESPONSIBILITY whether your insurance
company pays for your treatment or not. It is your responsibility to inform us of any changes in your
REGARDING INSURANCE PLANS WHERE WE ARE A PARTICIPATING PROVIDER: All ESTIMATED portions
and deductibles are due prior to treatment. In the event your insurance coverage changes to a plan
where are a non-participating provider, please refer to the above paragraph. You are responsible for
advising this office if you have a change in your insurance coverage PRIOR to your scheduled
TREATMENT PLAN ESTIMATES: We prepare TREATMENT PLAN ESTIMATES so that patients can
understand their estimated cost of recommended restorative treatment prior to start. The Estimate is a
good-faith attempt to predict the cost of your treatment based on the known facts when the estimate is
made. As your treatment progresses, your dentist may determine in consultation with you that
additional or a change in treatment may be necessary and that would change the estimated cost.
MISSED / BROKEN APPOINTMENTS: We respectfully ask that you give us a minimum 48-hour notice to
cancel or reschedule your reserved appointment. We kindly ask you to reschedule hygiene visits within
30 days of your recommended recall schedule. A broken appointment is defined as one for which the
patient failed to show-up or to cancel an appointment with less than 24 hours’ notice. As of January 1,
2022, this office will charge for broken appointments at a rate of $75 per hour. All charges for broken
appointments must be paid before any other appointments will be scheduled. All adult patients are
required to sign for minors/dependents and themselves.
ASSIGNMENT OF INSURANCE BENEFITS: I understand that services rendered to me by Dr. Melinda
Marino, DDS, Associate Dentist, and/or Hygienist (collectively labeled as “Provider”) are my financial
responsibility and that the Provider will bill my insurance company as a courtesy. I authorize my
insurance company to pay my benefits directly to Provider. I understand that I will be fully responsible
for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND
BENEIFTS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned
assignee, and I have agreed to pay, in a current manner, any balance of professional service charges
over and above this insurance payment.
I have been given the opportunity to pay my estimated deductible and co-insurance at the time of
service. I have chosen to assign the benefits, knowing that the claim must be paid within all state or
federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the
prompt payment of the claim by 25 days (electronically filed) or 45 days (paper mailed).
I authorize the Provider to release any information necessary to adjudicate the claim and understand
that there might be associated costs for providing information beyond what is necessary for the
adjudication of a clean claim. I also authorize the Provider to initiate a complaint to the insurance
commissioner for any reason on my behalf.
I understand that should my insurance company send payments directly to me; I will forward the
payment on to the Provider within 48 hours. I agree that if I fail to send the payment to the Provider,
and they are forced to proceed with the collections process, I will be responsible for any cost incurred by
the office to retrieve their monies. In the event the patient receives any check, draft, or other payment
subject to this agreement, I will immediately deliver said check, draft, or other payment to Provider.
Any violations of this agreement will, at Provider’s election, terminate Patient charge privileges with
Provider, as well as bring any balance owed by Patient to Provider immediately due and payable.
I authorize the dentist to release any information including the diagnosis and the records of any
treatment or examination rendered to me or my child during the period of such dental care to third
party payers and/or healthcare practitioners.
I grant my permission to your or your assignee, to telephone me at home, my work, or my cell phone to
discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to the contents.