Notice to all patients of office policy

Gordon A. Bech, DDS
925 Cross Gates Blvd.
Slidell, LA 70461

Please read and initial each item, then sign and date at the bottom:

1. I understand that office policy states that a $50 missed/broken appointment fee will be applied to any appointment that is missed, broken or cancelled less than 24 hours prior to the scheduled appointment time.

2. I understnad that if I carry a secondary or supplemental dental insurance plan, that I am solely responsible for filing and acceptance of payments from those plans. Dr. Bech or his staff will NOT file the secondary or supplemental dental insurance. In the event that payment is issued to Dr. Bech, a refund will be issued.

3. I understand that Dr. Bech will not file any medical insurance of workmen’s compensation policy or claim. Any claim that may need to be filed with either of these entities will be the sole responsibility of the patient. All procedures performed as a result of a medical or workmen’s compensation claim will need to be paid in full at a time of service.

4. I understnad that any returned checks will be assessed a $25 NSF fee and that future appointments will need to be paid in cash or with Visa or MasterCard.

5. I understand that if I am unwilling to give pertinent personal information (i.e social security number, insurance identification number) to be used for the sole purpose of filing for payment from my insurance provider that I will be responsible for cash only, payment in full prior to being seen by Dr. Bech or staff. If I refuse either option, I understand that I will be seen.

6. I understand that if I am unwilling to provide a current or updated medical history including medications I am taking, that is the right of Dr. Bech and/or staff to refuse treatment until this information can be provided.

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