This document serves to state certain office policies. This is not to be construed as the sole list or itemization of policies but those most commonly encountered. OFFICE POLICIES as of October 2019 1. PAYMENT: Is due at time of service, unless alternative arrangements have been made in advance. 2. BROKEN APPOINTMENTS: We reserve the right to charge a minimum of $85.00 for appointments canceled or broken without 24 hours advance notice. 3. INSURANCE As a courtesy, we will submit your dental claims directly to your insurance company. A per incident fee of $55 MAY be assessed for extensive insurance handling after your initial courtesy submission. 4. RADIOGRAPHS: Originals will remain the property of the practice; however duplicate x-rays will be furnished upon request for a fee. OUR DENTAL X-RAY POLICY X-Rays provide one of the best diagnostic tools in dentistry. They enable the dentist and hygienist to see inside the tissue of the teeth, gums and bones of the jaw. We assure you that we are conservative in our use of x-rays, but without them, decay and other oral diseases cannot be diagnosed until irreparable damage has been done. Millennium Dental Associates recommend that radiographs be taken at regular intervals for patients with no signs of decay or disease, and for diagnostic purposes when indicated. A full mouth series is needed every 3 years as well as four bitewing x-rays every year. Unfortunately, there will be no exceptions to these parameters, as doing so risks the health of your gums & teeth as well as generates unnecessary liability to the provider. If you have been seen by a dentist elsewhere, within the last year, and have had x-rays taken, it is important that we receive copies of these from your previous dentist. If they are of good quality, it may not be necessary to have them taken at your first visit here. Please complete a “Records Release” form and return it to the office. If no x-rays have been taken, or if the ones forwarded to us are not of good quality, we will need to take diagnostic films at your first visit here 5. I ATTEST that I am here of my own free will and personal choice, and not on behalf of any regulatory agency or investigative body. 6. I AUTHORIZE the use of any records (photos, models, etc.) for educational purposes. 7. CORRESPONDENCE: Any communication outside of your scheduled appointment such as phone consultations, emails, and written reports MAY carry a charge. 8. SCHEDULING: A NON-REFUNDABLE deposit may be requested prior to scheduling certain appointments. 9. MEDICARE: is not billed by this office. This office has “Opted-out of Medicare”. A form will have to be signed in office acknowledging this. (Medicare requirement, not ours). 10. DISPUTE: In the event of a dispute, the parties agree to abide by binding arbitration. 11. HIPAA: I hereby acknowledge, and have ready access to, and receipt of the office HIPAA Notice of Privacy Practices. It is also available on our website www.milldental.com