Δ
If the patient is not a minor, please disregard this section
If the patient is the responsible party, please disregard this section
If you're not using insurance, please disregard this section
If you have secondary dental insurance coverage, please let our office know
Private Practices: I (the patient) have the right to read the Privacy Practices. A copy of the Notice and/or this consent is available upon request and anytime on our website. The Notice provides a description of our practice's treatment, payment activities, healthcare operations and the uses and disclosures we make of your protected health information.
Purpose of Consent: I (the patient) understand and consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
Personal protected information cannot be shared with anyone unless otherwise allowed by HIPAA rules.
Thank you for choosing our office as your dental healthcare provider. Our goal is to help you achieve and maintain optimal dental care and provide a good doctor-patient relationship. Letting you know our Patient Treatment and Financial Policy in advance allows for a good flow of communication and enables us to achieve our goal. Please read this carefully, then sign below. Should you have any questions please do not hesitate to ask a member of our staff.
Please Note: Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, Discover, American Express.
Do you have insurance?
We encourage all our patients to take more responsibility in understanding their dental coverage. With the frequent changes in contracts, policies, and guidelines, it is impossible for us to keep track of the various insurance plans and requirements. As a courtesy to you, we will process your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. We will do all we can to ensure your estimate is as accurate as possible. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company.
We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office. I authorize the release of any information concerning my (or my child's) health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
We ask that you pay the deductible, co-payment and co-insurance, which is the estimated amount not covered by your insurance company, at the time we provide the service to you.
Insurance payments are ordinarily received within 30-60 days from the time of filing a claim. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
Missed Appointment (s) and Appointment Changes:
Our goal is to provide treatment in a timely manner with as few visits as necessary. In order to provide the best services to our patients, we require at least a 48 hour notice for changes to your appointments. We understand that unforeseen circumstances may arise, which may result in missing your appointment. A charge may be assessed for multiple missed, short notice or changed appointments.
Consent:
I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payableat the time services are rendered. I am obligated to pay said office in accordance with its credit terms and policy.
