Financial Policy and Agreement
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- Carmella Preston
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1 Financial Policy and Agreement Thank you for choosing us for your dental needs! We are committed to providing you with excellent care and convenient financial arrangements. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and patients financial capabilities. To confirm your understanding and agreement with our policies, please read the following. Payment: Ainslie Street Dental Centre files the primary and secondary insurance claims on behalf of the patients and requests their insurance company to pay the dental office directly. Patients are required to pay the remaining balance if the insurance company does not pay in full. We cannot waive co-payments and deductibles. This payment is required at the conclusion of the appointment. We handle all billing details with the insurance company. If the insurance company denies payment to the dental office directly, the patient will be notified and the patient will be responsible for payment to the dental office and collecting the money from their insurance company. Walk-in and emergency patients pay the dental office and claim the money from their insurance company. However, we will file the claim for you electronically. Non-insured patients Payment in full is due at the time services are rendered unless prior financial arrangements have been made. We accept Visa, MasterCard, Debit and Cash. Personal cheques are not accepted. Patients are provided with their bill and encouraged to review and understand what treatments were carried out. Electronic submission policy Your insurance claim form will be transmitted automatically to your carrier over the internet. A claim acknowledgment form will come directly from the insurance carrier. This form verifies that they have received your dental claim for processing, or an explanation of benefits form, which indicates the exact amount of the claim for which they will pay and your portion that is not covered. Unfortunately, not all insurance companies accept electronic submission. Therefore, we may need you to sign the manual claim form for processing. Insurance: Our office is committed to helping patients maximize their benefits and insurance policies vary greatly. Therefore, you are fully responsible for knowing your own dental insurance policy and what you are not covered for. Treatment is recommended based on what you need NOT on what is covered by your plan.
2 It is not always possible for us to find all the information concerning your insurance plan, as insurance companies are not obligated to disclose any or all information to us under the privacy act. We recommend that patients verify their coverage with their insurance company. Insured patients are encouraged to provide us the following information about their insurance policy. If in doubt, always ask the insurance company. Information required: Name of insurance carrier Policy number, certificate number(id)and division number(if any) The anniversary date of the policy, for example is it January 1 st or rolling calendar year The annual maximum benefit per patient per year The annual fee guide covered by their insurance policy (2011, 2012, and 2013 etc ) Percentage of coverage allowed for diagnostic, preventative, restorative, endodontic, periodontal services and all other major treatments, such as crowns, bridges and dentures. The per person and family annual deductible amount Number of scaling units covered per year and frequency etc As a courtesy, we will gladly send your claim electronically for you, on your behalf, to your insurance company providing that your company does allow electronic submission. Minors: A parent or guardian must accompany all minors to their dental appointments. The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit. It is not our responsibility. Missed Appointments: Once an appointment has been made a room is reserved specifically for you. Please be considerate and allow at least two business days to change or cancel an appointment in order to avoid a service fee. Service Charges: Service charges are applied on all overdue accounts. We understand temporary financial problems may affect timely payment of your balance in some cases. In those situations we encourage you to communicate any such problems immediately to our Front Desk team at ; they can be reached during regular business hours.
3 Financial Consent and Authorization for Treatment We wish to stress that the financial responsibility for services rendered rests with the patient and his/her family, regardless of any insurance coverage; your insurance policy is a contract between you and your insurance company. We cannot guarantee payment or coverage of your claim. I agree to pay all fees and charges for services rendered at Ainslie Street Dental Centre for myself and my family. I agree to pay all charges when presented with a statement, unless prior credit arrangements are agreed upon in writing. I understand and agree, regardless of my insurance status, I am ultimately responsible for any unpaid balance on my account. Print Name Signature Date
4 PRIVACY, DISCLOSURE, & CONSENT TO: Ainslie Street Dental Centre and Ainslie Street Dental Health Services Information for our Patients At Ainslie Street Dental Centre, all professional dental services are performed by licensed members of the Royal College of Dental Surgeons ( Dental Professionals ), and all institutional health care services are performed independently by Ainslie Street Dental Health Services, under the clinical supervision and control of Dental Professionals in a cost-sharing arrangement. Ainslie Street Dental Centre and Ainslie Street Dental Health Services are each independent entities providing independent services but for ease of administration may render joint invoices for their respective services. One or more of our Dental Professionals may have a financial interest in Ainslie Street Dental Health Services. Privacy Act and Consent to Treatment By signing this form, you acknowledge and agree that (i) you have read and understood the above information prior to any professional services being provided to you by any Dental Professional; (ii) you have been provided and have read a copy of the Privacy Code for Ainslie Street Dental Centre; and (iii) you agree to the collection, use and disclosure of your Personal Information in accordance with the Privacy Code. You can withdraw your consent at any time on the understanding that withdrawing your consent to certain information handling practices may impair the ability of Ainslie Street Dental Centre to provide the services you are requesting). Acknowledgement regarding Information Provided I, the undersigned, certify that I have provided and accurate and complete personal and medical dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding my medical dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. As discussed with me, I authorize the Dental Professionals and all professional staff working under the supervision and control of the Dental Professionals to perform diagnostic procedures that may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and I authorize the exchange of my personal information among Ainslie Street Dental Centre, Ainslie Street Dental Health Services, my medical doctor and another health care provider as reasonably necessary. I have been advised that this office maintains a Privacy Code and have been provided with a copy and that my personal information will be collected, used and disclosed within the guidelines of the Privacy Code. I also understand that my personal information will be retained by Ainslie Street Dental Centre and Ainslie Street Dental Health Services in accordance with their current practices, which may involve transfer and retention outside of Canada. I, the undersigned, acknowledge that the Ainslie Street Dental Centre and Ainslie Street Dental Health Services are relying upon the information which I have provided being accurate and complete.
5 Patient Name Patient Signature Date Reviewed by Ainslie Street Dental Centre Date
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Welcome to a Brighter Morgantown!
Welcome to a Brighter Morgantown! New Patient Information Payment Options E X C E L L E N C E I N D E N T I S T R Y S I N C E 1 9 2 7 Welcome to a Brighter Morgantown! Morgantown Dental Group would
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
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PAGE INTENTIALLY LEFT BLANK OFFICE DIRECTIONS Jordan Young Institute is located on Cleveland Street off Newtown Road. Cleveland Street from the Pembroke area ends at Clearfield. There is no direct roadway
Prince Family Dentistry
Prince Family Dentistry 702-240-0202 830 S. Durango Dr., Ste. 104 Las Vegas, NV 89145 PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married {
Singh Family Dental Dr. P. Singh, PLLC
Singh Family Dental Dr. P. Singh, PLLC 25 Country Club Road, #301 Gilford, NH 03249 (603)524-7455 251 Mayhew Turnpike Plymouth, NH 03264 (603)536-7600 260 Route 16B Center Ossipee, NH 03814 (603)539-4995
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Acknowledgement That You Have Received Our HIPAA Privacy Notice Simply Spoken Therapy is required by law to keep your health information and records safe. This information may include: Notes from your
Patient Registration PATIENTS WITH DENTAL INSURANCE ALL THIS INFORMATION IS NECESSARY TO VERIFY YOUR DENTAL COVERAGE!!
Patient Registration Patient Name Date of Birth Age If child, Parent's name: Mr. Mrs. Ms. Dr. I prefer to be called Single Married Divorced Widowed M F Address City St Zip. Home Phone( ) Cell Phone( )