PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION
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3 PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION Thank you for choosing Purcellville Pediatric Dentistry for your dental treatment. Dr. Monajemy is committed to healthy oral hygiene. Purcellville Pediatric Dentistry believes that everyone benefits from a clear financial agreement before treatment. This Payment Agreement is between Purcellville Pediatric Dentistry, a Virginia Professional Corporation, and you, the patient (or, if the patient is a minor, the patient s parent(s) or legal guardian). The terms of this Payment Agreement cover this visit and all future visits. This Payment Agreement amends the terms of any prior payment agreements you have had with Purcellville Pediatric Dentistry. Payments for today s visit and your future visits are due at the time of treatment. If you have dental insurance coverage, payment of the estimated patient co-payment is due at the time of service. INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE ARE NOT A PART OF THAT CONTRACT. IT IS YOUR RESPONSIBILITY TO KNOW YOUR BENEFITS. We file insurance claims on your behalf in order to help you get the coverage to which you are entitled. If your insurance company does not remit payment within 30 days after claims have been submitted, the balance will be required from you. The balances (including amounts due after insurance is partially paid or denied) must be paid within fifteen days of receipt of our invoice. While we are sensitive to divorce situations, our policy is to hold the parent seeking treatment for their child responsible for any charges not covered by insurance. We do NOT participate with any HMO OR DMO Insurances If you have an insurance plan that we do not participate with, you will be responsible at the time of service for any copay or percent of charges that your insurance plan does not cover. We will submit the claim on your behalf. All balances (including amounts due after insurance is partially paid or denied) must be paid within fifteen days of receipt of our invoice. If you have an insurance plan that we do participate with, you will be responsible for any copay or percent of charges that your insurance plan does not cover at the time of service. We will submit the claim on your behalf. All balances (including amounts due after insurance is partially paid or denied) must be paid within fifteen days of receipt of our invoice. Payment Options: We accept cash, checks, and Visa, Mastercard, and Discover credit or debit cards. For payment plan options ask us about Care Credit. We are pleased to offer 6 month or 12 month interest free financing for balances over $300.
4 Usual and Customary Rates: 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 s arbitrary determination of usual and customary rates. Interest: All balances (including amounts due after insurance is partially paid or denied) must be paid with fifteen days of receipt or your invoice. Balances remaining after this time will be subject to interest at a rate of 10% per year. Broken Appointments: We understand that occasionally circumstances arise that prevent you from keeping your appointment. However, time is reserved exclusively for you with the dentist and after one (1) broken appointment in your family, with less than 48 hours notice, there will be a charge to your account of $50 for each appointment that is broken. Your insurance company does not cover this charge. (if you provide us with a doctor s note that you were seen on the scheduled appointment date, we will credit the broken appointment fee.) Practice Dismissal Occasionally, we may find it necessary to dismiss a family from the practice. Reasons for this include, but are not limited to, the following: *recurrent late or missed appointments; noncompliance with recommended dental care; nonpayment of bills; threatening, abusive, or rude behavior toward office staff, doctors, or other patients and families. Collection Costs; Attorney s Fees; and Returned Checks You also agree to pay all costs of collections and attorney fees in an amount equal to 33.33% of the balance due on your account. There will be a $42 fee assessed on all returned checks. Law of the Commonwealth of Virginia This Agreement shall be construed in accordance with and governed by the laws of the Commonwealth of Virginia.
5 ACKNOWLEDGEMENT OF PRIVACY PRACTICES My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under Health Insurance & Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to: Provide and coordinate my treatment among a member of health care provides who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers for my health care services. Conduct normal health care operations such as quality assessment and improvement activities. I have been informed of my dental provider s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provides has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions, but if you do agree then you are bound to abide by such restrictions. I, the undersigned, certify that I have read the documents carefully, have a received and agree to the terms listed. Patient Name: Date: Signature Relationship to Patient Dependent family members also covered by this acknowledgement: For Office Use Only: We were unable to obtain the patient s written acknowledgement of our Notice of Privacy Practices due to the following reason: The patient refused to sign: Communication barriers: Emergency situation: Other:
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Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
Family Dentistry ANDREW P MINIGH DDS
PATIENT INFORMATION: Family Dentistry ANDREW P MINIGH DDS First Name: Last Name: Middle Initial: Address: City: State/Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security # Driver s