My signature below shall serve as authorization to assign any dental benefits paid by any third-party or insurer to my provider (Bellingham Family Dental - Erin McManus Walsh, D.M.D. PLLC). If I have insurance, I agree to make a payment of my estimated co-payment at the time services are rendered. I understand that estimated co-payments are estimates only, subject to policy maximums, limitations, and coordination of benefit rules.
This office will help prepare insurance forms and assist in making collection from insurance companies: however, payment is ultimately the patient’s sole and exclusive responsibility should the insurer or third-party payer fail, refuse or otherwise neglect to make payment. All collections from third-parties or insurers will be credited to the patient’s account. If I do not have insurance, all fees for services rendered are due on the date of service unless prior arrangements have been made in writing.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Out of courtesy to our staff, other patients and maintaining manageable costs to all our patients, please give us 48-hour notice if you need to cancel your appointment. This office reserves the right to charge a minimum fee of up to $75.00 for appointment missed or canceled with less than 48 hours advance notice. A missed Crown Appointment of 1.5 hours may be charged more. Returned checks from the bank will be billed at $45.00. All fees for services rendered are due on the date of service unless prior arrangements have been made in writing. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I agree to pay all costs of collection, including attorney’s fees and expenses, incurred to collect any unpaid fees.
Written copies of this policy are available to all patients. By signing below, I acknowledge that I have been offered a copy of this office’s Notice of Privacy Practices.
(If we are unable obtain written acknowledgement of receipt of our Notice of Privacy Policy, you will need to sign a declination)
I hereby authorize Bellingham Family Dental and its staff to disclose my protected health information with the person(s) indicated below. This authorization will remain in effect until I request a change.
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