New Patient Packet

Please correct the errors described below.

PATIENT REGISTRATION

Personal Information

Emergency Contact

Employer Information of Subscriber Insurance

Primary Insurance Information

If you do not know the following information please contact your insurance company by phone or internet.

Secondary Insurance Information

Referral Source

Dental insurance plans do not normally provide full coverage of your dental bill. Your dental coverage is a contract between you and your insurance company, and while we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account. Your portion of the bill will be due at time of service.

If your insurance has not paid within 60 days from the date from the date of service, we will look to you for prompt payment of the account. All costs for collection of the account, should collection procedures or small claims court become necessary, will be passed on to the patient and/or the responsible party.

I understand that, due to any false information, I will be subject to criminal prosecution

MEDICAL HISTORY FORM

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Women: Are you

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information ca be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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.

PATIENT FINANCIAL POLICY

Thank you for choosing Arizona Sunset Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering the following payment options.

You can choose from:
-CASH, CHECK, VISA, MASTER CARD, AMERICAN EXPRESS OR DISCOVER. There is a service charge of $35.00 for returned checks.

We offer a 3.5% courtesy accounting adjustment to patients who pay for their treatment with cash prior to completion of care for treatment plans of $500.00 or more

NO INTEREST* PAYMENT PLANS* FROM CARE CREDIT*

  • Allow you to pay over time with no interest*
  • Convenient, low monthly payment plans also available
  • No annual fees or pre-payment penalties

Please Note:
Arizona Sunset Dental requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.

For plans requiring more than 1 appointment, a two portion payment arrangements may be provided. For larger, more comprehensive treatment plans, a deposit of $50.00 is required to secure your initial appointment.

For patients with dental insurance, we are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement of your treatment. We do this as a courtesy to you and need you to be aware that the contract is between you and your insurance company. Any amount denied by your insurance company is the sole responsibility of the patient.

*A $50.00 fee is charged for patients who miss or cancel appointments without a 48 hour advanced notice.

Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.

We are here to help you get the dentistry you want or need. If you have any questions, please don’t hesitate to ask.

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.

ASSIGNMENT OF BENEFITS

Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

*Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.

*We ask you to sign this form and/or other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office.

*We ask that you pay the co-payment, which is the amount not covered by your insurance company, at the time we provide service to you.

*Insurance payments ordinarily are received within 30-60 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.

*We perform routine insurance billing procedures upon verification of coverage. Our office does not guarantee that your insurance company will pay for the treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time.

*We will cooperate fully with the regulations and requests of your insurance company. Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or question that may arise. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE DOCTOR.

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.

NOTICE OF PRIVACY PRACTICES

have read/ received a copy of the Notice of Privacy Practices for this office.

to receive information about my treatment, appointments, and balances.

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.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Your information will be encrypted.

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