I acknowledge that I have received a copy of MSW’s Notice of Privacy Practices.​ I understand that is my responsibility to clarify if I have co-pays and balances prior to appointments​. I understand that co-pays are due at the time of service unless other payment arrangements have been made in advance with MSW staff. I understand that if my insurance denies my coverage I am responsible for the full costs of the treatment I received (will receive), at MSW as determined by sliding scale fees.​ I understand that I am responsible for reporting phone number or address changes to MSW staff. I understand that if I do not confirm an appointment 24 hours before or do not leave a message, that appointment could be cancelled by MSW due to extreme need and limited availability of dental appointments.  I understand that if I fail twice to show up for general/hygiene appointments or once for a root canal without 24-hour notice to MSW, I will be discharged from the program and cannot reapply for one year (except in the case of an emergency). I understand that if I fail to keep an appointment due to an emergency, I can bring in appropriate documentation which will keep me admitted into the program.​ I understand that if I arrive more than 10 minutes late for an appointment without notifying MSW staff, my appointment will be marked as missed and I will not be seen that day.​ I understand that MSW may use my information in order to apply for funding that supports the clinic.​​ I understand that I must conduct myself in a civil and respectful manner to MSW staff. If I do not, I will be asked to leave the clinic and permanently discharged from the program.