Medicaid and Dental Wellness Treatment Agreement Form

Due to the low reimbursement rates and frequent missed appointments, patients MUST abide by the following requirements in order to receive treatment at Hart Family Dentistry:

If you are not seen within one (1) year of your last appointment, you will be considered a new patient. Under the current conditions we are not accepting new patients.

Because your scheduled appointment time is valuable to us and to other patients, your first failed appointment will incur a $30 fail fee. If you decide to continue treatment at our office, this fee must be paid prior to being scheduled for any other treatment. On the second instance of a failed appointment, you will no longer be able to be seen at this office. A failed appointment is when the patient or parent does not call and does not show up.

We understand that circumstances may arise that may prevent you from making your dental appointment. However, we expect a phone call when you cannot make it to your scheduled appointment. Too many (2-3) late cancelled appointments will also lead to termination of our relationship. A late cancelled appointment is any appointment that is cancelled with less than a 24 hour notice. This includes when we call you five (5) minutes after your scheduled appointment time to see if you are coming and you cancel at that time, no matter the reason.

You assume all responsibility for charges incurred during treatment that are not covered by your insurance. We will try to help you verify your eligibility, but cannot guarantee coverage. Eligibility for your insurance is an agreement between you and the State of Iowa, not Hart Family Dentistry.

Failure to abide by these rules will result in the termination of our treatment agreement. We try hard to complete quality dental care in reasonable appointment times and your participation is crucial. We thank you for understanding these terms of treatment and look forward to providing your dental care.

If our relationship has been terminated for any reason, you may complete a records transfer form and pay $10 (cash or credit card) to have your records transferred to another office.

If you agree to these rules, please sign on the signature pad. Your signature is proof that you have read this form and all of your questions have been answered.