The above information is accurate and complete to the best of my knowledge. I realize that it is my responsibility to notify this office if there are any changes in my health status. I authorize Dr. Kassel and his staff to perform any and all dental services that I may need during diagnosis and treatment. I know that this office strives to provide the highest quality of dental care possible and I expect that the care I receive in this office will meet or exceed the standards of care in the community, however, I realize that dentistry is not an exact science and that specific results of any dental treatment cannot be guaranteed. I understand and affirm that I am financially responsible for the total charges incurred for dental services rendered to me in this office. I also agree to be financially responsible for the total charges incurred for services rendered to my spouse and dependent children in this office. I authorize Lindenbrook Dental Care to keep my Credit/Debit Card on file to be used to charge for services rendered and any other fees due. I have read and agree to the terms of the Appointment Policy that is posted here and in the office as of the date of my signiture of this form. Our Appointment Policy is as follows: We will contact you, via your preferred method (text message, email, telephone call, or mailed reminder post card) four to five weeks ahead of time to remind you of your pre-booked hygiene appointment. Since most hygiene appointments are made three to six months in advance, we know that, as your pre-booked appointment approaches, things can come up that may cause the need for you to reschedule your appointment date and time. If you do need to reschedule, please let us know as soon as possible. We require “Sufficient Notice” to make any changes to your appointment. We consider Sufficient Notice to be no later than one week before your scheduled hygiene appointment. If you do not confirm one week before your appointment, your scheduled time slot will be automatically canceled, and your appointment time will be offered to another patient. Any changes made without Sufficient Notice will result in a Broken Appointment fee. We Require a Reservation Fee for making an appointment with our doctors. The reservation fee will be based on the time allotted for your appointment and the procedure(s) to be performed. At the time you make your appointment for dental treatment, you will be notified as to the amount required to reserve the time slot. If you keep your appointment, the reservation fee will not be charged or, if you desire, the reservation fee will be credited towards your out-of-pocket fees. Please decide if you wish to have the recommended treatment performed and make sure that you reserve a time for your appointment that you can commit to. If you do not keep your appointment with the doctor, your reservation fee will be charged. Sufficient Notice appointment changes apply only to cleaning appointments. Any changes to appointments with our doctors will always result in the reservation fee being charged. If you fail to keep your appointment, you will be charged a broken appointment fee. For cleaning appointments with the hygienist, the fee will be $50. For appointments with the doctor, the rate will be equal to the reservation fee. If there are extenuating circumstances which prevent you from keeping your scheduled appointment, Lindenbrook Dental Care reserves the right, at its sole discretion, to wave your broken appointment fee and reschedule your appointment for another time, or transfer your reservation fee to a rescheduled appointment. I authorize the use of my signature on all insurance submissions. I authorize this office to release all information necessary to secure payment of benefits. I authorize my insurance company to pay to Larry Kassel, DDS, PC, dba Lindenbrook Dental Care, all insurance benefits otherwise payable to me for services rendered. I understand that this office, as a courtesy to me, will process and submit claims to my insurance company and will estimate the portion of each claim that is expected to be covered by my insurance. I also understand that this is only an estimate of what my insurance will cover and that it is possible that my insurance will pay less or not at all. I realize that I am financially responsible for payment of any amounts that my insurance does not pay and that these amounts will become immediately due and payable upon notification from this office that it has determined that my insurance is paying less than expected. I realize that, if I would like to know the exact amount that my insurance intends to pay on a claim, it is my responsibility to ask the office to submit a predetermination of benefits, and I further realize that the amount that is shown upon the receipt of the predetermination of benefits is not a guarantee from the insurance company that they will cover the treatment submited to them on any particular claim form.
