BROKEN APPOINTMENT/LATE PATIENT POLICY

Similar documents
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other

Authorization to Release Health Information

Financial and Insurance Agreement

Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:

Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:

Patient Registration

Welcome to a Brighter Morgantown!

NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK

Premier Internal Medicine of Alpharetta, PC FINANCIAL POLICY

Permission Letter. Patient Name(s):

Dental Pros of Tampa. Kenneth M. Greenberg, D.D.S. & Nancy E. Freibaum, D.D.S., P.A. Appointment Scheduling Policy

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525

*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*

PPO/HMO/SELF-PAY PATIENT INFORMATION ACKNOWLEDGMENT FORM PATIENT RIGHTS AND ACKNOWLEDGMENT FORM

Patient Information. Name Birthdate Age. Single Married Separated Divorced Widowed. Cell Phone ( )

Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax

Patient Dental History

Hello and Welcome to Soft Tissue Solutions

FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.

GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

WELCOME TO SPORTS CONDITIONING AND REHABILITATION

CONSENT TO PROCEED. Patient Name: (Patient, legal guardian or authorized agent of patient)

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

The Pediatric Center of Stone Mountain, LLC. General Pediatrics, Adolescent Medicine & Behavioral Health Services

2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)

Consent for Services and Financial Policy

New Patient Information and Forms

Please print and complete all the enclosed forms and bring them to your first appointment.

DENTAL HISTORY. When was your last dental visit? Please describe the main reason for your consultation/new patient appointment:

New Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM. Name Date of Birth

Please print and complete all the enclosed forms and bring them to your first appointment.

Referred By: Can we contact?

Today s date: PATIENT INFORMATION. Address:

Welcome to Pediatric Dentistry of Greenville!

NEW PATIENT PACKET includes the following forms:

Acknowledgement of Privacy Practices

PATIENT REGISTRATION

Please complete the first page, as well as read, sign, and date the following pages. Please do not hesitate to ask us any questions.

Patient Acknowledgements, Agreements and Authorizations

PEDIATRIC PATIENT INFORMATION

PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY:

Financial Policy and Patient Agreement

Policies and information:

PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:

Office and Financial Policies

PATIENT REGISTRATION

DeMercy Dental Crabapple Road, Ste. 140 Roswell, GA

All About Kids Pediatric Dentistry

New Patient Registration

Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:

Eclectic Naturopathic Medical Center, LLC

Kathy A Curtis DDS, PLLC Downtown Dentistry

Sparta Dental Center Office Policy Statement

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

Clinic Hours Monday Friday 7:00 AM 4:00 PM (end times may vary); Select Saturdays (by appointment)

Carolina Dental Alliance

GENERAL INFORMATION 23. RESIDENTIAL CUSTOMER PAYMENT AGREEMENT STANDARD OFFER

538 SAVANNAH HIGHWAY CHARLESTON, SC (843)

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.

How did you hear about us? (Friend,Relative,Phone Book) Patient Information: Patient s Name: Male / Female: Last First Middle Preference.

Baldwin Counseling Payment Agreement

you like listed as your primary

WELCOME TO OUR PRACTICE

Please bring your insurance card, photo identification, and corresponding copayment with you when you check in for your appointment for all visits.

We are limited, not by our abilities, but by our vision.

PRIMARY CARE PHYSICIAN

Sierra Endocrine Associates Endocrinology, Diabetology & Metabolism

North Carolina Application for Dental Insurance

Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.

Patient Information:

SAGE DENTAL VIP 2018 PROGRAM ENROLLMENT FORM. Patient Name*: Patient DOB*: Patient Phone*: Patient Patient Address*: City*: State*: Zip*:

New Patient Information - Dr. Marc Edelstein

REASON FOR TODAYS VISIT Is this injury / condition related to your..

PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION

Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications

4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone

MacInnis Dermatology New Patient Registration Form

PATIENT REGISTRATION

FINANCIAL POLICY. General Information

Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS

Patient: Date: Address: City ST Zipcode. HPhone: Cphone . Can we leave message? Married Single Employed Student Full/PartTime

425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female

Family address preferred for patient portal access:

PATIENT REGISTRATION

CONSENT TO DENTAL TREATMENT

Subscription Agreement to CDAnet TM

ADULT PATIENT REGISTRATION

Who referred you to us? Who shall we contact in case of emergency? Phone:

Patient Safety and Privacy. Appointment Policy

Visa Health Savings Debit Card Agreement and Disclosure

Welcome to Pediatric Therapy Center, PC!

Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:

Welcome to ACRM! 1 ACRM

Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :

GENTLE DENTAL CARE OF ROCHESTER PC

Dear. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely,

Name: last First middle Address: street city state zip code Mailing Address: ( if different) street city state zip code

Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:

DATE: PRIMARY LANGUAGE SPOKEN: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT):

Transcription:

BROKEN APPOINTMENT/LATE PATIENT POLICY Reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients from receiving needed dental care in a timely fashion. Those who fail to keep scheduled appointments should not penalize the Dentist, our staff, and mainly our other patients. Our dental policy stipulates that failure to give sufficient notice to keep a scheduled appointment (1 working day notice) will result in a fee being charged. That charge is in accordance with our dental office s broken appointment policy for all of our patients. The patient is responsible for payment of the charge. ** If you have an e-mail address registered with our office you will be sent an e-mail reminder and you can confirm online. Otherwise, our staff will call 1 to 2 days prior to our scheduled appointment to confirm with you. We will attempt all numbers that you have provided us. If we have to leave a message on your machine or cell phone, it is your responsibility to call us back to confirm your appointment. Remember that we are closed early on Fridays so cancellations of Monday appointments must be called into us on Friday before 2pm. The usual and customary fee for broken appointments is $35.00 Patients who arrive more that 15 minutes late to their scheduled appointment time may be asked to reschedule as a courtesy to our other scheduled patients. (initial here) Patient, Parent, Guardian Signature Date

CANTON MARKETPLACE DENTISTRY PATIENT FINANCIAL POLICY As a service to our patients, CANTON MARKETPLACE DENTISTRY is more than happy to directly bill your insurance for your services rendered, but it is our policy that the patient is ultimately responsible for payment of services received from CANTON MARKETPLACE DENTISTRY. Your insurance policy is a contract between you and your insurance company. If your insurance does not pay the claim within 30 days mandated by the Georgia Law we will look to you for payment. As the patient, you are responsible for understanding your insurance coverage in relation to covered services and you are responsible for providing CANTON MARKETPLACE DENTISTRY with the most current insurance information. Patients who do not bring their insurance card for their appointment will be required to pay for services rendered at the time of service. Once the insurance is billed and payment has been received, CANTON MARKETPLACE DENTISTRY will refund any credits due to the patient. As part of our contract wtih your insurance company, we are required to collect your co-pay at each appointment without exception. This is not a policy credited by us, but is instead mandated by Georgia Law. All dental plans are not the same and do not cover the same services. In the event your dental plan determines a service to be "not covered", or you do not have an authorization, you will be responsible for the complete amount. We will attempt to verify benefits for some specialized services; however, this is not a guarantee of payment and you remain responsible for charges of any service rendered. All patients are encouraged to contact their plans for clarification of benefits prior to your appointment. You will receive a statement of any amount owed after your insurance pays. The balance is due within 15 days. If payment is not received in full and it is necessary to send an additional statement, there will be a $10.00 billing fee added for each additional statement you receive. Please understand that repeated efforts to contact patients for payments owed is both time consuming and costly. Past due account are subject to collection proceedings. All fees including, but not limited to collection, fees, attorney fees shall become your responsibilty in addition to the balance due this office. Our goal is to provide you with exceptional care and service. We are committed to helping your fulfill your financial commitment to CANTON MARKETPLACE DENTISTRY. If you have any questions or concerns regarding our financial policy our Office Manager will be happy to discuss them with you. Signed: Date: (Patient or person legally authorized to consent for patient) Printed Name:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback