Online Form

INSURANCE (IF APPLICABLE):

Please check if the patient has a history of the following medical conditions:

Please check if the patient has, or ever had, any of the following habits?

Thank you for choosing us as your dental provider. We are committed to providing you with excellent patient care. The following is an explanation of our Financial Policy, which you must read and sign prior to any current and future dental evaluation or treatment in this office.

1. Each patient is responsible for his/her own account. Patients who have no insurance are required to pay 100% of services at time of treatment. If this is not possible, you will need to make payment arrangements with our office prior to any dental evaluation or treatment. We accept cash, personal check, Visa, MasterCard, American Express, Discover and Care Credit.
2. Your dental insurance policy is a contract between you and your insurance carrier. We are not a party to that contract. As a courtesy, this office will submit all claims to your insurance carrier. In order to facilitate claims processing, you must provide all insurance policy information and changes to our office. Your bill is your responsibility whether your insurance company pays or not. At times, you may need to contact your insurance carrier regarding non-payment of your insurance claim(s).
3. You are responsible for knowing what procedures and providers are covered by your dental plan. Any service provided, but not covered by your insurance company will be your responsibility
4. If your insurance company has not paid your full account balance within 90 days, you must pay the outstanding balance without further delay.
5. Payments on accounts billed are expected within 30 days. Delinquent accounts will be charged interest at 1.5% per month.
6. The undersigned specifically agrees to pay all attorneys’ fees and court costs in the event that legal action is taken to collect on an account. The undersigned further agrees to pay an additional amount representing up to 40% of the principle balance if the account is referred to a collection agency or attorney for collections. This additional amount is in recognition of the cost associated with said collection action processing.
7. Patients who fail to appear for their scheduled appointments may be charged a $35 missed appointment fee, unless the patient cancels the appointment at least 24 hours prior to their appointment.

Our fees for dental services reflect the usual and customary fees in the community. You are responsible for payment regardless of any dental insurance company’s arbitrary determination of usual and customary fees for dental services. If our office is a preferred provider with your insurance company, we will abide by their usual and customary rates. However, you will still be responsible for your portion of the bill that they do not pay and for services that are not covered on your policy.

I hereby authorize this office to release information concerning my dental treatment to my insurance carriers.

I further authorize and direct said agency, attorney or insurance company to pay from the proceeds of benefits of any recovery or insurance payments in my care, directly to the providers of this office for their professional services rendered. I understand that this in no way relieves me of my personal responsibility for paying my provider when treatment is rendered. It is understood that the signing of this form does not prohibit customary monthly billings.

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act). I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following:

• Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment.
• Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
• The day to day healthcare operations of your dental practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA. I understand that your reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.