New Patient Form

Patient Information

Relationship Status
Sex

Is patient covered by another dental insurance?

Responsible Party Information

Patient Consent Form

I understand that I have certain rights regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment.)
• Obtaining payment from third party payers (e.g. my insurance company)
• The day-to-day healthcare operations of your 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 and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change terms of this notice from time to time and that I may contact you at any time to obtain 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 health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then 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 revoked this consent is not affected.

Financial Policy

We file dental insurance claims for our patients as a courtesy. We cannot bill your insurance company unless you provide all the necessary information required for us to do so. Please understand that your insurance policy is a contract between you and your insurance carrier- we will make every attempt possible to collect from your insurance company, however all balances on your account are ultimately your responsibility.

Please be aware that some or all services rendered may not be covered under your policy. As the policyholder, you will be responsible for knowing the terms and limitations of your policy.

Co-payments and deductibles are expected at the time of service. If your insurance company reimburses you, payment in full will be required at the time of service.

No Show Appointments

Patients that do not attend their scheduled appointments will be charges a no show fee of $50.00. If you must cancel your appointment in advance, please give the office at least 2 business days advance notice by phone or email.
Phone: (817) 873-3300