Patient Form

EMERGENCY CONTACT INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

** YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT**

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 MEDICAL HISTORY

PATIENT DENTAL HISTORY

AUTHORIZATION AND RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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.

OUR FINANCIAL AGREEMENT

Thank you for choosing Capitol Dental Associates LLC as your dental care provider. We are committed to your treatment being as pleasant and stress free as possible. The following is a statement of our Financial Policy, which we require you to read and sign prior to dental treatment. Please understand that payment of your bill is considered part of your treatment.

Regarding Insurance

We accept assignment of insurance benefits. The insurance policy is a contract between you and your insurance company. We are not a party to that contract. All contracts have limits and/or various degrees of co-payment. Please make yourself aware of this specific plan prior to your visit(s). To obtain plan information often you may discuss this with your human resources department, or, call the number listed on your dental insurance card. The treatment recommended by our office is never based on what your insurance will pay; it is based upon our dedication to giving our patients the highest quality dental care. We strive to give patients informed opinions regarding what is best for their oral health. IT IS THE PATIENT’S RESPONSIBILITY TO INFORM THE OFFICE OF ANY INSURANCE CHANGES.

We will do our best to estimate what the patient portion will be for future services; this is based upon the information given to us by your insurance company. This estimate amount should NEVER be considered a guarantee of how much your insurance plan will cover nor how much you will be responsible for. Whether your insurance company pays or not, the balance due is ultimately your responsibility. If your insurance company has not paid your account in full within 45 days, the balance will automatically be transferred to the patient balance and billed directly to the patient.

Regarding insurance plans where we are participating provider: All co-pays and deductibles are due at the time of any visit. In the eventthat your insurance coverage changes to a plan where we are not participating providers, refer to the above paragraph.

FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD, DISCOVER, AMERICAN EXPRESS, ANDCARE CREDIT.

Adult Patients

Adult patients are responsible for full payment at time of service

Minor Patients

The adult accompanying a minor is responsible for full payment. Any divorce decrees stating financial responsibility do not pertain to dental visits. The parent or adult here at the time of treatment is responsible to pay the visit. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized IN WRITING to an approved credit plan or paid by cash or check.

Missed Appointments

Unless canceled AT LEAST 24 HOURS in advance, you will be charged a $50.00 fee for your missed appointment. Reminder calls by our office are a courtesy and should not be relied upon. It is your responsibility to record your appointment dates and times and to show up for your appointments, whether you receive an appointment alert or not. Patients who do not show up for their appointments will be billed regardless if they had received a reminder call or not.

Repeated failed appointments will result in discharge from our care

You agree that interest at the rate of one and one-half percent per month will be due to this office if any account balance is delinquent more than forty-five days. Although the interest at the rate of one and one-half percent will start to accrue on the forty-sixth day that an account is overdue, the interest itself will not be posted to the account on a continuing basis until the last day of the month in which interest becomes due and payable.

In the event your account is turned over to an attorney for collection, you will be responsible and hereby agree to be responsible for all court costs, State Marshal’s fees and reasonable attorney’s fees. The court will determine attorney’s fees where an attorney on behalf of Capitol Dental LLC brings any legal action.

*PLEASE SIGN AND DATE BOTH STATEMENTS AFTER YOU HAVE COMPLETED READING OUR POLICY.

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.