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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*
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A copy of our Notice of Privacy Practices was made available and I, [FName] [LName], acknowledge receipt of that notice.
Do we have your permission to transmit your information by conventional email to other offices for referrals or communication? There may be some level of risk that the information in these emails could be read by a third party. We currently use a HIPAA compliant encrypted email service.
I have had the full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permision.
Patient, Parent or Guardian's Signature
NOVEL Coronavirus Disease (COVID-19)Screening Questionnaire Consent Release
Screening: Select Yes or No:
1. Have you traveled internationally in the last 14 days? Yes No2. Have you been in close contact with another person who has been diagnosed with/under investigation for COVID-19? Yes No3. Do you have a cough, fever, or shortness of breath? Yes NoGeneral Release:COVID-19 is the infectious disease caused by the most recently discovered coronavirus. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019.I acknowledge that I have truthfully and honestly answered yes to all the questions above, and I am in the office and receiving this dental treatment of my own free will and volition. The Patient now and forever releases the Practice and any of its affiliated companies, Cincinnati Insurance Company any of its affiliated companies, patients or potential patients, subsidiaries, divisions, and all present and former owners, employees, officers, directors, successors and assigns (whether acting in their individual capacities or as agents for the Practice or a related entity, collectively, the “Released Parties” from any and all Claims against contracting COVID-19 from this office.Consent to Treatment:I understand that being in this office and receiving dental treatment I may be at risk of being infected with COVID-19. As with all social contact at this time, there are risks of contracting COVID- 19.By consenting to treatment, you are acknowledging your willingness to accept known risks and complications of contracting COVID-19 no matter how slight the probability of occurrence.Patient or Representative Signature:
OFFICE FINANCIAL POLITY Due to a recent increase in the amount of last minute cancelled or "no show" appointments, we are implementing the following new policies. We understand that unanticipated events happen occasionally in everyone's life, the late train or last minute meetings etc. But in our desire to be effective and fair to all our patients, the following policies are in effect at AGAPE DENTAL STUDIO.Scheduled Appointments- When a patient schedules an appointment they are responsible for that date and time. Our office provides many ways to remind patients of their appointments as a COURTESY. We send text or email reminders and also call patients. Patients are ultimately responsible to confirm their scheduled appointments. If there is no confirmation your appointment may be given to someone else to avoid an unproductive schedule in our office.24 Hours Advance Notice- If you are unable to make your CONFIRMED scheduled appointment we do ask you to give the office 24 hours’ notice. This allows the opportunity for someone else to schedule an appointment at this time. If the CONFIRMED appointment is not cancelled within 24 hours a $50.00 cancellation fee will be applied to your account.No Shows- Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a NO SHOW and a $50.00 missed appointment fee will be applied to your account.Late Arrivals- If you arrive late, your appointment may be shortened in order to accommodate others whose appointment follows yours. Depending upon how late you arrive, your Dr. will then determine if there is enough time remaining to start your treatment. Out of respect and consideration to your Dr. and staff and other patients, please plan accordingly and please be on time.We value all of you as patients and look forward to seeing you at your next appointment here at AGAPE DENTAL STUDIO!
I have read and agree to the terms in this OFFICE FINANCIAL POLICY.
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Relationship to Patient* --Select-- Self Spouse Child
Group Number
Name of Insured*
Insured Social Security Number
Insured Birth Date (mm/dd/yyyy)*
Employer Name
Ins Company* --Select Company-- 3M Dental Services Aarp Dental Ins. Plan C/O Delta Dental Aetna Dental Plans Ameritas Anthem Blue Cross Anthem Blue Cross Assurant Employee Benefits Assurant Health Blue Cross Blue Shield Of Oregon Blue Cross And Blue Shield Of Alaska Blue Cross Blue Shield Of Ca Blue Cross Blue Shield Of Illinois Blue Cross Blue Shield Of Massachusetts Blue Cross Blue Shield Of Ok Blue Cross Blue Shield Of Tx Blue Cross Life And Health Blue Cross/Blue Shield of Hawaii Blue Shield Of California Blue Shield Of California Blue Shield Of California Blue Shield of California Blue Shield Of California Carrington Cigna Delta Dental Delta Dental Aarp Delta Dental Healthy Families Delta Dental of Arkansas Delta Dental Of Arkansas Delta Dental Of California Delta Dental Of California/Tricare Retir Delta Dental Of Colorado Delta Dental Of Florida Delta Dental Of Hawaii Delta Dental Of Illinois Delta Dental Of Iowa Delta Dental Of Kansas Delta Dental Of Kentucky Delta Dental Of Massachusetts Delta Dental Of Michigan Delta Dental Of Minesota Delta Dental Of Missouri Delta Dental Of New Jersey Delta Dental of Oregon Delta Dental Of Pennsylvania Delta Dental Of Rhode Island Delta Dental Of Tennessee Delta Dental Of Wisconsin Dentemax/Surency Dentical Direct Reimbursement Dental Plans Of Ny, Geha Connection Dental Federal Golden West Dental Great-West Healthcare Group Administrators Ltd. Guardian Health Partners Humana Dental Humana Dental Life Wealth Management Lincoln Financial Group Lincoln Financial Group MetLife National Elevator Industry Benefit Plans (NEIB) Northeast Delta Dental Premera Blue Cross Premier Access Insurance Principal Reliance Standard (Asrm) Safeguard Samba Sun Life Financial United Concordia Washington Dental Service Other
PLEASE CAREFULLY READ BELOW:
I, THE UNDERSIGNED HEREBY AUTHORIZE THE DOCTOR TO TAKE X-RAYS, STUDY MODELS, PHOTOGRAPHS, OR ANY OTHER DIAGNOSTIC AIDS DEEMED APPROPRIATE BY THE DOCTOR TO MAKE A THOROUGH DIAGNOSIS OF THE PAITENTS DETERMINED NEEDS. I ALSO AUTHORIZE AGAPE DENTAL TO PERFORM ANY AND ALLFORMS OF TREATMENTS, MEDCIATION THAT MAY BE INDICATED. I ALSO UNDERSTAND THAT THE USE OF ANESTHETIC AGENTS EMOBIDIES A CERTAIN RISK AND UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE CARRIER AND ME, AND BETWEEN THE INSURANCE CARRIERS AND AGAPE DENTAL, AND THAT I AM FULLY RESPONSIBLE FOR ALL DENTAL FEES. THESE FEES ARE DUE PAYABLE AT THE TIME OF SERVICE. I ALSO ASSIGN ALL INSURANCE BENEFITS TO AGAPE DENTAL. I FURTHER UNDERSTAND THAT AN ADDITIONAL CHARGE WILL BE ADDED TO ANY OVERDUE BALANCE. I HAVE READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTICE AS REQUESTED BY HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (“HIPAA”).
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