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Note: We do not share or sell your data. The information you provide is encrypted and directly sent to our system and it is not stored online.
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Disclaimer
I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.
Patient or Guardian Signature *
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Patient or Guardian Signature*
I understand that my initial visit may require radiographs to complete the examination diagnosis and treatment plan. I understand that Westside Dentistry has set standard intervals for radiographs to aid in the diagnosis of oral lesions, decay between the teeth, bone loss, gum disease, cysts, tumors, infections, and impacted teeth.Initials:
I understand the treatment involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal disease. I understand bleeding could last several hours. Should it persist, particularly if it is severe in nature, it should receive attention and this office must be contacted.
I understand that a 30% deposit will be required on all dental treatment prior to scheduling the appointment.
Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health.The following is a statement of our Financial Policy, which we require that you read, agree to and sign priorto any treatment. As a courtesy to you, we will help you process all of your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurancewill pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contactyour insurance company for a detail of your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate aspossible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with yourinsurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’sarbitrary determination of usual and customary rates.We ask that you pay the deductible, co-payment and co-insurance, which is the estimated amount not covered by your insurance company as services are rendered. 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 insurancecompany 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. We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance companyover any claim. Minors accompanied by the parent or legal guardian: The parent or legal guardian accompanying a minor, who has consented to treatment are responsible for full payment at time of service. Unaccompanied Minors:The parent or legal guardian is responsible for full payment at time of service. Missed Appointment (s) and Cancellations: 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 24 hour notice for cancellations or for re-scheduling yourappointments. We understand that unforeseen circumstances may arise, which may result in canceling or missing your appointment. A $75 charge may be assessed for multiple missed, short notice or cancelledappointments. 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 dentalservices provided in this office for myself or my dependents is mine, due and payable at the time services are rendered.Communications with you: By signing below, you are authorizing us to call you at any number you provide including calls to mobile/cellular or similar devices for any lawful purpose. You agree to any fees or chargesthat you may incur for an incoming call from us, and/or outgoing calls to us, to or from any such number, without reimbursement from us. We or our agents may call by telephone regarding your account. You agreethat we may place such calls using an automatic dialing/announcing device. You agree that we may make such calls to a mobile telephone or other similar device. You agree that we may, for training purposes or toevaluate the quality of our service, listen to and record phone conversations you have with us.
Sincerely,
Westside Dentistry
Patient’s Name
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Patient’s signature
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:ï‚·
May we phone, email, or send a text to you to confirm appointments? Yes No May we leave a message on your answering machine at home or on your cell phone? Yes No May we discuss your medical condition with any member of your family? Yes No
If YES, please name the members allowed:Name of Member Date of Birth: Name of Member Date of Birth:
Patient, Parent or Guardian's Signature
In regards to the person named above, if not himself or herself, I hereby authorize photos, xrays or any other recorded material created during the care and treatment or after its completion to be used for either the advancement of dentistry or in promotional materials. These include educational, research-related, public service, and promotional purposes. This may include, without limitation, uses such as: inclusion on a website, brochures and other publications in print or electronic media, catalogs, press releases.
The person's identity will not be revealed to the general public. To be more specific, full face photos, date of birth, address, social security number and other identifying information ARE NOT INCLUDED IN THE RELEASE above and cannot be divulged.
State relationship to person above if not an adult: Parent Guardian Self