Financial and Insurance Agreement

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5 Financial and Insurance Agreement I understand that payment for my dental treatment is due in full at the time services are rendered. The office accepts cash, check, Visa, Master Card, Discover. A service fee of $35.00 will be charged to me should the office have a check returned from my bank for insufficient funds. If my treatment costs exceed what I can pay I will be offered a 6 months interest-free payment plan option (on approved credit) through Care Credit. This financial arrangement must be made before any dental service will be performed. If I have dental insurance now or in the future the office of Dr. Ryan K. Love will promptly submit my claims for my treatment on my behalf as a courtesy to me as long as I have provided them with accurate insurance billing information. I will be required to pay the estimated co-payment and deductible on or before the day of my treatment. The limitation of benefits I receive from my insurance company depends on the plan, I or my employer has chosen, not the fees of the dentist. I am responsible for all charges not covered by my plan, including all fees considered above the insurance policy s usual and customary fee schedule. Since the dental office does not know the exact amount my insurance company will pay for any procedure, I understand I will receive a statement for any balance on my account after the insurance company has paid; even if I made a co-payment the day of treatment. My statement will have a due date and I understand I will receive a finance charge in the amount of 1.8% per month if the balance is not paid in full on or before that date. The office will allow insurance up to 60 days to pay on a claim and I will be informed if additional information is needed from me to process a claim. The office will not carry any balance longer than 90 days; therefore, I will be informed if my account is delinquent so I can pay the balance in full to avoid collection actions outside the dental office that may affect my credit. Should my past due balance be turned over to collection agency, I understand that I will be responsible for all fees (attorney, court cost, etc.) related to the collections of my account. I have read and agree to the terms and conditions of the above financial policy. I understand that this document is now a permanent agreement for as long as I am a patient of Dr. Ryan K. Love, DDS. Patient or Responsible Party: Date: Dr. Ryan K. Love, D.D.S North Argonne Road - Spokane Valley, WA Phone: Fax:

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7 PATIENT HIPAA CONSENT FORM I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment means providing, coordinating, managing health care and /or related services by one or more health care providers. Examples of treatment would include office visits, x-rays, wart removal, office surgery etc.; Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your medical plan for your medical services.; Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Signed this day of 20. Print Patient Name Signature Relationship to Patient Dr. Ryan K. Love, D.D.S. 807 N. Argonne Road Spokane Valley, WA Phone: Fax

8 How would you like Love Family Dentistry to communicate with you? Our dental office sends appointment reminders, information about treatment, payment and insurance, and other communications. Please tell us how you would like us to communicate with you. Your Name Today s Date Check or complete all that apply (please print clearly): Contact me by U.S. Mail at the following address: Contact me by at the following address: Phone and Text Communications for Appointments: Phone Number: By checking this box, I consent to the following: The dental practice or its service provider may contact me to provide health care information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing. The dental practice may: Call me Text me Both Signature Date If your phone number or insurance has changed please provide us with correct information prior to your next appointment. Dr. Ryan K. Love, D.D.S North Argonne Road - Spokane Valley, WA Phone: Fax: