AUTHORIZATION
I
authorize my insurance company to make payments directly to the dental
office for benefits otherwise payable to me. I authorize release of
my records to third party payers, other
healthcare professionals
or operations, or other entities as deemed necessary by this
office. I authorize use of this signature for all insurance
submissions. I understand that I am responsible for all changes
whether or not they are covered by insurance, as well as any
additional collection costs if this office determines they are
necessary.
I
authorize this office to charge my credit card or bank account for
any unpaid balances, including those after insurance payment. I
understand that in certain circumstances, my credit report may be
requested. I understand that check payments may be converted to
automatic bank drafts. I have
reviewed the information on this
form, and is accurate to the best of my knowledge.
Patient, Parent or responsible party
DENTAL
OFFICE INFORMED CONSENT
It
is important to us that you, our patient, understand the treatment we are
recommending and any invasive procedures we may, with your agreement, perform.
We want to involve you in all decisions concerning invasive procedures you may
need. We take informed consent very seriously in our office. Therefore, we
only want you to sign this form when you understand that there is a risk
associated with dental procedures, and all your questions have been answered.
Dental
treatment and procedures are not to be taken for granted as being routine or
without risk for complications. As with all medical treatment to one's body,
including dental treatment, there are no guarantees that the results will be as
planned and to each individual's satisfaction. When dealing with the human
body there are potentially many variables, some predictable and others are
not. Complication rates in dentistry are low but do exist. Even a minor
procedure like "filling" can lead to major complications that cannot be
foreseen. For example, "Novacaine" injection could lead to allergic reaction,
anaphylaxis, facial hemorrhage, swelling, bruising, and even hospitalization
or death. Granted these are fairly uncommon occurrences but individuals who
are contemplating this should be aware of this prior to consenting. Whenever
drilling is involved, even a simple cavity can lead to pulpal (nerve)
problems, abscess, fractured tooth, and/or post treatment pain to biting and
to temperature extremes (hot and cold). These complaints can be transient
or may persist requiring further treatments. The above examples are only
samples of possible complications with dental treatment and are not limited
to these. In general, complications include but are not limited to pain,
swelling, bleeding. infection, and other nerve problems.
I
have read, understand and consent to dental treatments.
Patient's
signature
NOTICE
OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT
I have received this practice's Notice of Privacy
Practices written in plain language. The Notice provides in detail the uses and
disclosures of my protected health information that may be made by this
practice, my individual rights, how I may exercise these rights, and the
practice's legal duties with respect to my information. I understand that this
practice reserves the right to change the terms of its Notice of Privacy
Practices, and to make changes regarding all protected health information
resident at, or controlled by, this practice. I understand I can obtain this
practice's current Notice of Privacy Practices on request and going to www.opalfamilydental.com/privacy-practices.
Signature
of responsible party
OFFICE
POLICY
When
we make your appointment, we are reserving a room for your particular needs. We
understand that extreme or unavoidable emergencies or circumstances do arise
which may require you to cancel your appointment. We
ask that if you must change an appointment, please give us at least 48
hours
notice. This courtesy
makes it possible to give your reserved room to another patient who would
like it. We
reserve the right to charge for any appointment(s) broken without a 48 hours
notice. The charge will be $50.00 for every thirty minutes of appointment
time. Repeated cancellations or missed appointments will
result in loss of future appointment privileges.We
feel that our patient's time is valuable. When your appointment is made, a room
is reserved, your records are prepared, and special instruments are readied
for your visit. Except for
emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the
same courtesy from you.
Checks
returned from the bank is subject to $ 35.00 service fee. Accounts
delinquent more than 60 days from the date of billing are subject to a 1.5%
per month (18% annually) finance charge. If your account is sent to our
collection agency you will be responsible for collection
and court costs
along with attorney's fees.
If
you have any questions regarding our policies and your treatment, please do
not hesitate to ask.
OUR
FINANCIAL POLICY
Thank
you for choosing us as your dental care provider. We are committed to your
dental treatment being successful. We agree in writing with every patient to
sign our financial policy, as we have found with our past experience that
this policy makes our mutual experience easier and without confusion. This
policy is to ensure that all of our patients receive a highest level of
quality dental care in a friendly and healthy environment while
understanding their financial responsibilities. This policy as well as
other health and insurance forms provided must be read, agreed to, and
signed prior to any dental treatment.
Cash
Patients
Patients
with no insurance are expected to pay in cash, check or credit card the day
the service is rendered, unless specific arrangements are made in advance.
Insurance
Patients
For
those patients covered by insurance, we may accept assignment of benefits.
This means you must sign the portion of your insurance form that assigns
payment to our office. Very few insurance policies cover 100% of the cost of
your treatment. In this day and age many cover 50% or less on many services
and actually cover nothing on others. Due to this, and the frequent delays in
receiving payment from the insurance company, you will be asked to pay your
deductible and your portion of
your charges the day the service is
rendered. We will estimate as closely as possible, your coverage, but until we
actually receive the payment from the insurance company, it is just an
estimate. Some patients request that we send in a pre -determination to
their insurance carriers. We state what treatment you need, and they tell
us what they will cover on that treatment plan. Many patients prefer to
get service started immediately, and some treatments should be started
immediately. In these cases, we will ask you to pay for your services in
full as they are done, and when the insurance company pays their portion we
will reimburse you for what they pay. We will assist you in dealing
with
the insurance company, but ultimately the responsibility of payment and
insurance problems lies with you. If we do accept assignment of benefits
from the insurance company, if the insurance company hasn't paid after
45 days, the full balance is expected from you personally.
The
above policies apply equally to parents and guardians of minors being treated,
and minors cannot he treated without a parent or guardian authorizing
treatment and agreeing to financial responsibility. Thank you for reading and
understanding our financial policy. If you have any questions or concerns;
please feel free to ask them at any time. We wish to be of assistance in any
way we can.
I
HAVE READ AND UNDERSTAND THE ABOVE DENTAL
OFFICE INFORMED CONSENT, OFFICE
POLICIES ANDFINANCIAL POLICIES.
Signature
of responsible party