New Patient Forms
My Time Dental Centers is committed to providing exceptional service and treatment that addresses both your short- and long-term needs.
1. A Clear, Written Estimate on your Cost of Treatment
Dr. Schmelter will provide you with a comprehensive treatment plan based on your overall health. You will also receive a clear, detailed estimate of the cost of your plan, including your estimated insurance benefits. If you have questions regarding your insurance coverage, please contact your insurance company.
2. Financial Agreement
- a) I agree to pay a $35.00 Fee on all returned or cancelled checks.
b) I understand there is a NO SHOW/CANCELLATION FEE for all appointments. There may be a fee of $50 and will be changed per hour of time scheduled. Please give 48-hour notice if you are unable to keep your appointment.
3. Payment Policy
- a) Full payment of what you owe (called the Patient Financial Responsibility amount, as noted in your Treatment Acceptance and Payment Arrangement Form), is due when services are rendered. We accept cash, personal checks, Visa®, Master Card®, American Express®, Discover®, assigned insurance benefits, and select third-party financing programs.
b) 10% Discount for our uninsured cash/check paying patients, cannot be combined with any courtesy discounts.
4. Dental Insurance
If you have dental insurance, your insurance claim will be processed as follows:
- In Network: If your dentist is a participating provider in your insurance network, you will be billed according to the terms of your dentist's agreement with your insurer.
- Out of Network: If your dentist is not participating or in-network provider with your insurance plan, we will honor your carrier's in-network fee structure. If your insurance carrier will not accept your assignment of benefits to your dentist, you are responsible for the estimated insurance benefit.
Insurance Discounts: Insurance companies often negotiate discounts for services provided to their plan members. If you exceed your annual benefit limit the insurer's discounted rate may apply to additional services as a benefit to you.
5. Third-Party Financing
My Time Dental Centers accepts payment from non-affiliated, third party finance companies. Credit decisions are the responsibility of these third-party finance companies. You may choose to pay all or a portion of your treatment using approved third-party financing products.
6. Patient Communication
We'd like to keep in touch regarding your upcoming appointments, treatment plan, and treatment status. By providing your email address, phone number, and mailing address, you are giving My Time Dental Centers permission to contact you through one or all of these communication methods. Note that email and text messaging is not secure and there is a risk that they could be read by a third party. By sharing your email or mobile number with us you are acknowledging that you are aware of this risk and agree to receive this type of communication.