Thank you for choosing our office as your dental health care provider. We are committed to providing you with
the highest quality lifetime dental care so that you may fully attain optimum oral health. Everyone benefits when
office and financial policy arrangements are understood. In order that we may have a definite understanding in
regard to the payment for dental services, the following is our policy. Payment is due at the time service is
provided. We accept cash, personal checks, cashier's checks, money orders, Visa, Mastercard, Discover and
Patients who carry dental insurance understand that all dental services furnished are charged directly to the
patient and that he or she is personally responsible for payment of all dental services regardless of dental
insurance. As a courtesy to you we will help you process all your insurance claims. We ask that you pay the
deductible and co-payment, which is the estimated amount not covered by your insurance company at the time
we provide service to you. We must emphasize that this is only an estimate and that all charges you incurred are
your responsibility regardless of your insurance coverage. Insurance companies have a wide variety of rules,
plan limitations and exclusions that our office may not be aware of. Dental insurance is a benefit for you that is
provided by your employer, and the terms of your benefits are between you, your employer and your insurance
company. Our office is not a party to those terms or agreements. We will cooperate fully with the regulations and
requests of your insurance company in order to assist in the claim being paid. However, this office will not enter
into a dispute with your insurance company over any claim.
Once insurance has paid their agreed benefits, a statement will be sent to you for any remaining balance, and will
be due upon receipt. If your insurance company has not made payment within 60 days, the unpaid balance
becomes your responsibility and is subject to finance charges and the collection process.
On occasion, a grandparent or a single parent will be the responsible party and bring a child in for their dental
treatment. Since it is our office policy to provide a treatment cost estimate before your scheduled appointment,
please make arrangements for payment before dental treatment is rendered.
Cancellation & Late Policy:
Your appointment time is reserved for you. If you are late for your appointment, we may not be able to
accommodate you. If you think that you will be late, please call as soon as possible so that we may advise you if
your late arrival can be accommodated, or if we will need to reschedule you. We maintain a very busy schedule
and must insist that appointment times be respected. If a cancellation is necessary, we require 24 hours
advanced notice. An answering machine is available for messages left after business hours. Without a 24hr
cancellation notice a fee will apply.
We thank you for the opportunity to serve your dental health care needs and welcome any questions you may
have concerning your care or our policies. Significant costs are incurred in carrying our patients' accounts. To
control these costs and help keep fees down, it is necessary to adhere to these policies.
CONSENT: I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I
AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO GENE HASSELL DDS.
The undersigned hereby authorizes Dr. Hassell to take X-rays, study models, photographs, or any other diagnostic
aids deemed appropriate by Dr. Hassell to make a through diagnosis of my dental needs. I also authorize Dr.
Hassell to perform any and all forms of treatment, medication and therapy that may be indicated. I also
understand the use of anesthetic agents embodies a certain risk, I understand that responsibility for payment for
dental services provided in this office for myself or my dependents is mine, due and payable at the time services
are rendered. I further understand that a finance fee, rebilling fee, collection fee or attorney fee will be added to
any overdue balance.