Maitland Square Dentistry

Thank You for choosing us as your Dental health care provider, we are committed to your treatment being successful. Please Understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment.

All patients must complete our information and insurance form before seeing the Doctor.

Regarding Insurance: We will gladly process your insurance claim as a service to you at no charge during regular business Hours M-Fr from 9 am to 4 pm. Please note that our fees are not based upon any insurance schedules, and may be above insurance allowances, unless we are contracted with a specific insurance company. In addition, any estimate that we provide to you is only an estimate; You are responsible for ALL FEES in their entirety. Although we will make every effort to help you understand and obtain your benefits, we cannot guarantee what your insurance provider will pay. The amount of reimbursement is determined by the insurance carrier. We do not accept the responsibility of collecting on an insurance claim or for negotiating a settlement on a disputed claim.

Please note however, that any and all services provided for immediate care needs for out of town patients, outside Seminole county, Florida or outside regularly scheduled business hours will not be reported nor processed with insurance, nor will retroactively be processed with insurance at a later date. Insurance is not accepted outside regular business hours, and the final fee is the patient’s / guardian’s entire responsibility. In order for contracted fees with an in Network Participating Insurance to be honored, the Insurance information MUST be presented AT THE TIME OF SERVICE during regular business hours. Your insurance is a contract between you and your insurance company. We are not a party to that contract and ultimately you are responsible for all charges incurred at our office. Dental insurance is not meant to be a "pay all" option but meant to be an aid. So please be aware that some and perhaps all of the services provided under your particular policy may be considered non-covered benefits, above their usual and customary fee or based on a set "fee schedule". Your benefits are dependent on how much your employer paid for your particular plan. If you have any questions regarding the details of your plan, we ask you to contact your company. Regardless of what insurance pays, the final balance on your account is considered your responsibility. Please understand that we cannot predict exactly what your insurance company will pay on a particular procedure or service and is only an estimate determined of the charges based on the information your insurance company is willing to provide us. An annual deductible and any required co-payment on a particular service will have to be collected at the time of service, and can only be based on the general information released by your insurance company. Usual and Customary Rates: Dental insurance usually covers basic dental procedures. Emergency Dental Services, Complex comprehensive procedures and high tech implants or major complex cases will be reported as usual and customary and will not be reported as insurance contracted fees.

In the Event the insurance company pays the patient: Occasionally, an insurance company will send a payment directly to you, the patient. If this occurs, please bring the check and attached explanation of benefits to our office. Any attempt to collect from said insurance funds not entitled to the patient will be perceived as fraud and will be prosecuted to the full extent of the law.

Collection Process: If for any reason we need to collect the balance, the patient or his/her legal guardian agrees to pay any and all costs of collections, not limited to or excluding, of a collection agency fees, all attorneys' fees, court costs, and bank fees, if collected by and through an attorney, plus interest on said account, whether or not suit is filed. In the event of any litigation relating to this policy, the exclusive venue shall be in Seminole County, Fla.

* At our office, we strive to provide you with the best dental care. Should any of the treatment that we provide you fail prematurely, we offer a personal guarantee that any moneys applied to prior treatment, will be applied complementary towards any future permanent dental work at the Doctor’s discretion.

Disputes and Litigation: Any disputes, litigation or claims made against The Orlando Oral Implant Center and any of their employees, arising out of treatment or omission to treat shall solely be the patient’s financial responsibility (or his/her legal guardian) who willfully agrees to pay any and all final court costs, not limited to or excluding, of collection agency fees, all attorneys' fees, and all bank fees, if collected by and through an attorney, plus interest on said account, whether or not suit is filed.

Abandonment of Care by the Patient: If ANY dental work is commenced, payments must be made prior treatment. If any dental work is initiated at our office, and is not completed in a timely manner due to patient refusal, NO Refunds may be offered at this time.

* If any dental appliance is fabricated at our office, and patient refuses to have appliance delivered, NO Refunds will be offered.

* If any root canal is initiated, and not completed in a timely manner due to patient negligence, no moneys is to be refunded at this time, and the patient may be referred to another office to have completion of the procedure performed at their expense.

Cancellation Of Appointments: If for any reason you are unable to keep your appointment kindly give us 48 HOUR notice. Without proper notification Broken appointments are subject to $ 100 fee for routine dental appointments. For extensive procedures involving Implant Surgery or Major Complex Cases, Without a 48-hour notice your account will be charged $500 per scheduled hour. Please note that our answering service or voicemail or email CANNOT accept cancellations.

I authorize Dr. David Hazan to perform any necessary dental treatment. I understand that there are possible risks and complications with any procedure. I do not hold Dr. David Hazan liable for any complications that may arise during any dental procedure.

I have received a copy of "Notice of Privacy Practices" from Dr. David Hazan's office and have read it fully. I am giving my consent to use, and disclosure of my protected health information to carry out treatment, payment activities and any other health care operations by Dr. David Hazan's office.

I authorize David Hazan D.M.D., and staff to color photography of my teeth or face for reproduction and viewing by other dentist or physicians for scientific or educational publications or presentations at dental meetings. I also consent to having all surgeries performed on me videotaped. I understand that it is for my own protection and for the protection of Dr. Hazan and staff, the entire office is under open camera surveillance and agree to proceed with dental treatment under these conditions.

I authorize David Hazan D.M.D. and staff to keep my credit card number on file so that balances not paid by insurance companies may be charged to my credit card not to exceed the total Treatment Plan Price.