Our Office Visit Policies

Columbia Regional Center for TMJ and Orofacial Pain believes that part of good healthcare practice is to establish and communicate a clear financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy. Please take time to carefully review the following information and return this form to the front desk with your signature and today’s date.

RETAINER FEE: A $200 retainer fee will be collected at the beginning of your first appointment. This fee will be applied to the cost of service.

MISSED APPOINTMENTS/CANCELLATIONS: At Columbia Regional Center for TMJ and Orofacial Pain, our goal is to provide quality care in a timely manner. We have implemented a no show and cancellation policy which enables us to better utilize available appointments for our patients in need of care. The following policy is with regard to patients who fail to keep or arrive late to their scheduled office visit. When you schedule an appointment with Columbia Regional Center for TMJ and Orofacial Pain, we set aside enough time to provide you with the highest quality care. Please be courteous and call in advance if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another person the possibility to have access to care. Current patients need to contact the office 24 hours in advance if they wish to cancel their appointment. Those who fail to show for their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time will incur a $99 fee to be paid prior to reschedule. This fee is the responsibility of the patient and is not covered by insurance. Those who arrive late will have their appointment time adjusted to end on time. New Patients that do not show to their appointment or do not give 48 hours’ notice may reschedule after placing down a scheduling deposit.

INSURANCE: It is the patient’s responsibility to provide our office with current insurance information. We will ask for your insurance card at your first visit and will copy for our records. Your insurance policy is a contract between you and your insurance company. It is the patient’s responsibility to know the terms of their insurance plan. As a courtesy we file all your claims for you. However, we will not become involved in disputes between you and your insurance carrier. This includes, but is not limited to, deductibles, co-payments, non-covered charges and “usual and customary” charges. We will supply information as necessary. If your insurance company does not pay the practice within a 45 days you will be billed. If we later receive payment for your insurer, we will refund any overpayment to you.

SELF-PAY PATIENTS: This category includes patients with no insurance and those who wish to not file with their insurance. Payment for medical services is required prior to services being rendered. We accept cash, personal checks, Credit/Debit cards, and CareCredit.

OUTSTANDING BALANCE/NSF CHECKS: If your insurance company has not paid the balance in full, you will receive a statement notifying you of the amount due. We accept cash, personal checks, Credit/Debit cards, and CareCredit. A $30.00 fee plus any bank charges will be charged for any NSF/returned checks. You are ultimately responsible for the timely payment of your account.

LATE CHARGES: Balances that are not paid within 30 days of the first statement are subject to a 5% per month interest. Delinquent accounts will be required to pay fees prior to future service.

COLLECTION FEES: I understand that in the event my account is placed in collection status, any additional fees incurred due to this, will be added to my outstanding balance. This includes but is not limited to late fees, collections agency fees, court costs, interest and fines. I understand that these additional fees will be my personal responsibility to pay in full.