Rays. Do not use Hex-Rays brand assets in a manner that implies Hex-Rays endorses or authorizes your content, organization, services, or products unless you have explicit written permission from Hex-Rays to do so. Do not use Hex-Rays brand assets in a manner that implies a partnership without a formal partnership agreement in place or express written permission. We suggest that you include a disclaimer of association or endorsement where appropriate. (E.g., “Hex-Rays is not associated with, nor does it endorse or sponsor this [website/prod- uct/event/content/etc].”) No inappropriate prominence. Do not display Hex-Rays brand assets in a manner that makes them the most distinctive or prominent feature on your web page, printed material, or other content without express written per- mission from Hex-Rays to do so. Example of prohibited use: Organizing an event where there is very little presence of your organization’s brand in the signage, but a huge Hex-Rays logo banner. No objectionable or unlawful use. Do not display Hex-Rays brand assets in a manner that is misleading, unfair, defamatory, infringing, libelous, disparaging, obscene, or otherwise objectionable to Hex-Rays. Do not display Hex-Rays brand assets on websites or materials whose content violates the law. No merchandise/manufactured goods. Do not display Hex-Rays brand assets on physical or commercial goods without express permission from Hex-Rays to do so, even if they are not for sale.
Rays. If you have current x-rays from a previous dentist, it is your responsibility to bring those to your appointment or to arrange for their transfer. If you do not notify us that you have current films/digital X-rays, we will take new ones. Insurance companies have limitations on how often they will pay for x-rays. Therefore, it is important that you let us know if you have had recent ones taken outside of our office. Patient Responsibility of Balances: You will be responsible for: Services not covered by insurance, co-pays, deductibles, and balances remaining after your insurance company has paid. Payment in full is expected within 30 days from your first statement advising you of the balance due. For your convenience, we accept cash, personal check, Visa, MasterCard Discover, and American Express as forms of payment. If a check is returned to us for any reason, a $35.00 fee will be charged. A monthly billing charge of $5 will be assessed on all accounts over 60 days old. You are responsible for the timely payment of your account. In the event that your payments are not received in a timely manner, you will be responsible for the cost of collection. Missed Appointments: Your good dental health is or main objective. Therefore, it is extremely important for you to keep all of your scheduled appointments. We understand that emergency situations do arise that may require you to change an appointment. As a courtesy to other patients and our office, we ask for 48 hour notice of any change to your appointment. If any appointment is failed, or repeatedly changed, a fee will be charged and/or you may be asked to find a new dentist. Acknowledgement and Authorization: I have read, understand, and agree to the above policies listed on page 1 and page 2. Regardless of any insurance I may have, I am ultimately responsible for payment of any professional services rendered. I authorize the release of medical information necessary to process a claim for benefits under my policy and assign payment of my insurance benefits to Main Street Family Dentistry, P.C. If my account should become delinquent, I agree to pay the costs of collection, including agency fees, attorney fees, and court costs. Name Date 20
Rays. If you are a new patient, we will take X-rays as part of the initial exam and to establish a baseline. Current x-rays ( within the past 12 months) will be accepted if present at time of service/exam. Existing patients will require updating x-rays yearly to assists in monitoring for possible changes. Missed appointments Our office appreciates a 48 hours notice during business hours for all cancellation appointments. Multiple cancellations or no show are subject to a $75 fee per patient, per incident. Consent and Authorization I have read and understand the document in its entirety. I agree to abide by the office policies outlined. Patient's Name (Print) Patient's Signature Date Minor Patients The adult accompanying the minor is responsible for payment on the account. Non-emergency treatment will be denied unless charges have been pre-paid. In Case of a Minor Xxxxx's Name Your Relationship to Minor Responsible Party (Print) Responsible Party's Signature
Rays. The x-rays performed in our office constitute an integral part of the medical records. Fees for x-rays are for the professional services rendered and medical information obtained, and are not to be misconstrued as a purchase of films. Our practice reserves the right to keep all original films, and in such cases will arrange for copying of any requested x-rays for a fee. This request must be made in writing and fees prepaid. Please allow a minimum of 7 business days for x-ray copying. X-rays will not be mailed.
