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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*
COVID-19 PANDEMIC - PATIENT DISCLOSURES
This patient disclosures form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at a greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immunse system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
I fully understand and acknowlegde the above information, risks, and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.By signing this document, I acknowledge that the answers I have provided above are true and accurate.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
FINANCIAL POLICY Thank you for choosing us as your dental health care provider. We are happy to have you as our client and look forward to offering you and your family the finest dental care available at affordable fees. Before your care, we will discuss and present treatment recommendations and fee options. This will allow you to fully understand your dental care, what to anticipate in fees and allow you time to make the necessary budgetary arrangements. We are committed to your treatment being successful. FULL PAYMENT IS DUE AT TIME OF SERVICEFor your convenience we accept Cash, Visa, MasterCard, and American Express. A bookkeeping courtesy of 5% is offered on pre-paid treatment exceeding $1000 with cash only. To receive this courtesy your treatment has to paid in full when you schedule. This cannot be combined with any other savings. INSURANCEI assign my insurance benefits to Dr Sheetal Suryawanshi DMD . I understand that this form is valid until cancelled by me through written notice to Sheetal Suryawanshi Inc. Having insurance is not a guarantee of payment to us. All charges to your account are your responsibility regardless of insurance benefits. Your insurance policy benefits are determined by your employer and not your dentist. We will make every effort to keep your policy particulars on file; however, please understand that the information provided to us is purely an estimate. Any deductible or estimated co-payment amount will be expected at the time of treatment. Your policy is a contract between you and your insurance company; we are third party to that contract. As a courtesy, we will be glad to file your claim for you if you bring: 1) your dental insurance card and 2) all required employer information. You will be expected to pay for services rendered if this office is unable to verify your insurance information before treatment. If your insurance claim is not paid within 45 days, we do expect you to clear the pending insurance claim balance in full. We will make every collection effort with your insurance; however, we do expect your involvement, as the relationship is between you and your policy organization.ALL PAYMENTS ARE FINAL AND NON-REFUNDABLE! RETURNED PAYMENT FEE$95.00 will be added for returned checks or credit card charges.FINANCINGFor your convenience, we do offer affordable financing options with little to no interest. Upon credit approval, these arrangements are made individually with our Financial Administrator prior to commencing treatment. A 1.5% monthly service charge will be applied on all account balances greater than 60 days. Collection fees may apply for delinquent accounts.
MISSED APPOINTMENTS:
Your reserved time in our office is important. We understand that sometimes it is necessary to change your appointment so we ask that you kindly give us a minimum of 2 business days notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. If 1 or more appointments are broken in a 12 month period without 2 business days notice, a cancellation fee of $50 will be applied to your account Unpaid balance over 30 days old will be subject to monthly interest of1.5% (APR 18%). If payment isdelinquent, the patient will be responsible for payment of collection,attorney’s fees, and court costs associated with the recovery of the monies dueon the account.I have read the Bliss Dental Lounge Financial Agreement. I understand and agree to this Financial Agreement.
If for any reason your insurance company does not pay the estimated amount, it will become your responsibility. I understand and agree to this Financial Policy. I understand that the dental office will do their best in estimating my insurance benefits. I agree that I am responsible for paying any co-payments at the time of service. I also agree to be responsible to expeditiously pay the dental office for any unforeseen uncovered services. Patient's Signature: