Patient Relationship, Financial Responsibility, and Professional Services Policy

 

CONSULTATION, FINANCIAL, DEPOSIT, CREDIT, CANCELLATION, AND REFUND POLICY

Effective Date: June 23, 2026

 

This policy applies to services provided by Minimally Invasive Jaw Surgery, LLC, including services rendered through The International Center for TMJ & Jaw Surgery and Mama's Pediatric Dentistry.

 

OUR COMMITMENT

 

As a family-owned healthcare organization, we are committed to providing compassionate, professional, patient-centered care.

 

We believe successful healthcare relationships are built upon mutual trust, honesty, communication, professionalism, and respect. Just as patients are entitled to competent and respectful care, providers and team members are entitled to a safe and respectful environment in which to deliver that care.

 

The Practice believes healthcare relationships function best when patients, families, providers, and team members interact with kindness, honesty, professionalism, and mutual respect. We are committed to listening to concerns thoughtfully and addressing them in a fair and respectful manner, and we ask the same of those we serve.

 

CONSULTATION SERVICES

 

Consultation fees compensate the Practice and provider for professional expertise, clinical judgment, diagnostic review, treatment planning considerations, and individualized recommendations.

 

Consultation services may include:

• Review of medical and dental history

• Clinical examination and evaluation

• Review and interpretation of diagnostic imaging

• Discussion of diagnoses, treatment options, risks, benefits, limitations, and alternatives

• Surgical candidacy assessment

• Treatment planning recommendations

• Referral recommendations when clinically appropriate

• Coordination of care considerations

 

Patients are paying for the provider's expertise, interpretation, professional judgment, and recommendations—not for a guarantee of surgery, treatment approval, insurance coverage, symptom resolution, or any particular recommendation.

 

A recommendation against treatment, against surgery, or in favor of a second opinion does not diminish the value of the consultation provided.

 

TREATMENT RECOMMENDATIONS AND PROFESSIONAL JUDGMENT

 

Healthcare providers maintain independent professional judgment regarding whether treatment is clinically appropriate, medically indicated, safe, and aligned with a patient's goals and long-term interests.

 

Recommendations may include:

• Surgical treatment

• Conservative treatment

• Observation

• Additional diagnostics

• Referral to another provider

• Recommendation against treatment or surgery

 

Completion of consultation paperwork, imaging, records, scheduling, or payment does not obligate the Practice to provide surgery, treatment, sedation, or any specific procedure.

 

Recommending another provider, second opinion, or subspecialist should not be interpreted as a denial of care, but rather as part of the Practice's commitment to helping patients make informed healthcare decisions and pursue the treatment path most aligned with their goals and circumstances.

 

The Practice reserves the right to decline treatment, postpone treatment, transfer care, refer care elsewhere, or discontinue non-emergency services when deemed clinically appropriate, safety-related, outside the scope of the Practice, or incompatible with an effective provider-patient relationship, consistent with applicable law.

 

DIAGNOSTIC IMAGING AND RECORDS

 

CBCT imaging, radiographs, photographs, digital scans, diagnostic records, and professional interpretation of those records are professional services that become part of the patient's healthcare record.

 

Once obtained, reviewed, interpreted, or performed, these services are generally not refundable.

Patients remain entitled to copies of their records and imaging in accordance with applicable law and Practice procedures.

 

Upon appropriate authorization, records may be forwarded to another provider to facilitate continuity of care.

 

PATIENT-SPECIFIC DEVICES, APPLIANCES, AND PRODUCTS

 

Certain products, appliances, devices, splints, orthotics, exercise equipment, therapeutic aids, and treatment-related products are ordered, dispensed, fabricated, designated, or customized for use by an individual patient.

 

For health, safety, infection-control, regulatory, and product integrity reasons, patient-specific devices and appliances are generally not returnable and not refundable once dispensed, delivered, ordered, opened, fabricated, or placed into service.

 

Examples may include:

• Oral appliances

• Splints and orthotics

• OraStretch devices

• Therapeutic exercise devices

• Custom-fabricated appliances

• Patient-specific treatment aids

 

The patient's decision not to use, discontinue use of, or decline future use of a device does not generally create eligibility for refund.

 

The Practice may, at its discretion, accept return of certain items; however, return of an item does not guarantee eligibility for refund, credit, or reimbursement.

 

PROFESSIONAL SERVICES PROVIDED OUTSIDE OF SCHEDULED APPOINTMENTS

 

Healthcare providers may occasionally provide professional services outside of scheduled appointments, including but not limited to:

• Review of extensive patient communications

• Review of outside records or imaging

• Extended treatment coordination

• Medical necessity documentation

• Letters, forms, reports, and appeals

• Telephone consultations

• Video consultations

• Portal or email consultations requiring clinical review or professional judgment

 

Most routine communications are provided as a courtesy and are not separately billed.

However, when communications, record reviews, treatment coordination, consultations, or documentation require substantial provider time, clinical analysis, medical decision-making, or administrative effort beyond the ordinary scope of routine patient communication, the Practice reserves the right to bill for professional services using applicable medical or dental billing codes or private fee schedules.

 

Patients may be notified when communications or consultations are expected to generate billable professional time.

 

REFUNDS

 

Refunds are generally reserved for:

• Duplicate payments

• Verified billing errors

• Insurance overpayments

• Insurance adjustments resulting in a patient credit balance

• Payments collected for services not rendered

 

In these situations, patients may elect either:

• Refund of the overpayment

• Credit toward future services

 

SERVICES ALREADY RENDERED

 

Once professional services have been rendered, refunds are generally not available.

 

Examples include:

• Consultations

• Clinical examinations

• CBCT imaging

• Radiographs

• Diagnostic records

• Treatment planning

• Surgical planning

• Professional interpretation of records or imaging

• Provider time reserved and utilized

 

Healthcare services involve professional expertise, analysis, judgment, and time that cannot be returned once delivered.

 

TREATMENT PACKAGES AND RECOMMENDED FOLLOW-UP CARE

 

Certain services may be offered as part of a treatment package, monitoring program, bundled service, comprehensive treatment plan, or recommended course of care.

 

Package pricing may reflect the overall course of treatment and monitoring recommended by the provider rather than individual visits or services viewed in isolation.

 

Patients remain free to decline recommended follow-up appointments, discontinue care, or seek care elsewhere. However, unused portions of treatment packages, monitoring programs, bundled services, or recommended care pathways are generally not refundable unless otherwise specified by the Practice.

 

The Practice's recommendation for follow-up care reflects professional judgment regarding what is believed to be in the patient's best interests and long-term health and should not be interpreted as a guarantee that future treatment will be required.

 

Patients who elect not to participate in recommended follow-up options offered by the Practice, including in-person or telehealth appointments when available, generally remain financially responsible for previously purchased treatment plans, packages, or services.

 

GOODWILL CREDITS

 

The Practice recognizes that unique circumstances may occasionally arise.

Although services already rendered are generally not refundable, Practice leadership may elect to provide a goodwill credit toward future services when deemed appropriate.

 

Goodwill credits:

• Are discretionary

• Are not guaranteed

• Do not constitute an admission of fault or wrongdoing

• Do not establish precedent

• May be applied toward future services deemed appropriate by the Practice

• May, with approval, be transferred to an immediate family member

• Have no cash value unless otherwise required by law

 

These credits may be denied when continuation of the provider-patient relationship is not clinically appropriate or when the therapeutic relationship has broken down.

 

TREATMENT DEPOSITS

 

Certain procedures require deposits to reserve provider time, operating room resources, anesthesia services, laboratory resources, surgical planning, administrative coordination, and other treatment-related expenses.

 

Deposit requirements vary depending upon the procedure and may be modified by the Practice.

 

Examples may include:

• Orthognathic Surgery – approximately 20% of the patient portion

• Total Joint Replacement (TJR) – approximately 50% of the patient portion

• Arthroscopy – approximately 25% of the patient portion

• Other surgical procedures as determined by the Practice

 

These percentages are examples and may change based upon the nature and complexity of treatment.

 

SURGICAL PLANNING AND EARNED DEPOSITS

 

Certain procedures require substantial work before the date of treatment.

 

Treatment planning, administrative coordination, operating room scheduling, anesthesia scheduling, custom device fabrication, implant planning, imaging review, provider preparation, and related services may begin well in advance of the procedure date.

 

As these services are performed, portions of a deposit may become earned and may no longer be eligible for refund.

 

TOTAL JOINT REPLACEMENT (TJR)

 

Because significant planning, coordination, case preparation, custom fabrication, and provider resources may be committed well before surgery, TJR deposits are generally considered earned as planning progresses.

 

ORTHOGNATHIC SURGERY

 

Orthognathic surgery deposits reserve provider availability, operating room resources, treatment planning services, and administrative coordination. Cancellation or postponement may result in partial forfeiture of the deposit depending upon timing and resources already committed.

 

ARTHROSCOPY

 

Arthroscopy procedures require scheduling of providers, staff, anesthesia services, equipment, and clinical resources.

 

Patients providing at least twenty-one (21) days' notice prior to a scheduled arthroscopy may be eligible for transfer of their deposit to a future treatment date or practice credit.

 

Cancellations occurring within twenty-one (21) days may result in partial or complete forfeiture of the deposit when anesthesia costs, staffing commitments, scheduling commitments, or other unrecoverable expenses have already been incurred.

 

FAILURE TO FOLLOW PRE-OPERATIVE INSTRUCTIONS

 

Patients are responsible for complying with all pre-operative requirements and instructions.

 

Examples may include:

• Fasting requirements

• Escort requirements

• Medication instructions

• Medical clearance requirements

• Arrival times

• Required documentation

 

If a procedure cannot proceed because required instructions were not followed, the Practice may retain all or a portion of the deposit to offset costs associated with reserved provider time, anesthesia services, staffing commitments, facility resources, and administrative expenses.

 

The Practice may, at its discretion, apply some or all of the deposit toward a future treatment date or practice credit.

 

NO-SHOWS AND LATE CANCELLATIONS

 

Failure to appear for a scheduled appointment without notice or cancellation with insufficient notice may result in forfeiture of deposits, loss of reserved appointment times, additional scheduling requirements, or future deposit requirements.

 

ABUSIVE OR EXCESSIVE COMMUNICATIONS

 

The Practice is committed to responding to reasonable patient questions and concerns.

 

Repeated, excessive, harassing, abusive, threatening, manipulative, dishonest, disruptive, duplicative, or otherwise inappropriate communications that substantially interfere with patient care, provider availability, staff operations, or the Practice's ability to serve other patients may result in:

• Requests to consolidate communications through a designated channel

• Scheduling of a formal consultation appointment

• Billing for professional time when applicable

• Transfer of care or termination of the provider-patient relationship consistent with applicable law

 

COMMUNICATION AND RECORDING EXPECTATIONS

 

The Practice values open, transparent communication and understands that patients may wish to review important healthcare discussions.

 

Patients are encouraged to inform providers and staff if they intend to make audio or video recordings during appointments or communications so that all participants may communicate openly and accurately.

 

To protect the privacy of other patients, visitors, and team members, recording may not be permitted in certain areas or circumstances.

 

Secret recordings, selective editing of communications, publication of recordings, or conduct that materially disrupts trust within the provider-patient relationship may be considered when determining whether continuation of non-emergency services remains appropriate.

 

PATIENT RESPONSIBILITIES

 

Patients are expected to:

• Provide accurate and truthful information

• Follow reasonable treatment recommendations and instructions

• Communicate concerns respectfully

• Treat providers, staff, and other patients with courtesy, kindness, and respect

• Keep appointments or provide appropriate notice

• Fulfill financial obligations for services rendered

 

PRACTICE STANDARDS OF CONDUCT

 

The Practice is committed to maintaining a respectful environment for patients, providers, visitors, and staff.

 

Threatening, abusive, discriminatory, harassing, coercive, dishonest, disruptive, or unsafe conduct may result in dismissal from the Practice, denial of future scheduling, denial of discretionary credits, or termination of the doctor-patient relationship, consistent with applicable law and continuity-of-care obligations.

 

REVIEW OF REFUND OR CREDIT REQUESTS

 

Requests for refunds, credits, financial accommodations, or deposit exceptions should be submitted in writing.

 

The Practice reviews each request individually and generally provides a response within thirty (30) days.

 

The Practice recognizes that unforeseen circumstances may occur. While this policy establishes general guidelines, Practice leadership retains discretion to evaluate individual circumstances and determine whether a credit, transfer, accommodation, or exception is appropriate.

 

POLICY MODIFICATIONS

 

Minimally Invasive Jaw Surgery, LLC reserves the right to modify this policy at any time.

 

By scheduling an appointment, signing intake paperwork, receiving services, or otherwise engaging the Practice, the patient acknowledges understanding and acceptance of this policy.