EMERGENCY CONTACT
DENTAL INSURANCE INFORMATION
I Have Read The Above Information And Authorize The Payment To The Doctor Named Above. I Authorize And Give My Consent For Treatment To Be Rendered By The Doctor Named Above. I Also Authorize Dentista De La Comunidad To Submit Any Medical Information Necessary To Process My Dental Insurance Claims.
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.
Welcome to our practice! We appreciate the trust you have placed in us.
Professional services are rendered and charged to you, not your insurance company. Please understand that the contract is between you and the insurance company and payment for the services is your responsibility. We will accept the assignment of claims for primary insurance. All deductibles and fee amounts not covered by insurance are due at the time of treatment.
Our office will not enter into a dispute with your insurance company over your claim. This is your responsibility and obligation. lf at the end of 90 days, your insurance company has not paid, you are responsible for the entire balance. Upon request, we will supply you with a copy of the claim so that you can resubmit if necessary.
ln order to honor any insurance benefits, you must provide insurance identification and we must be able to verify the current benefits available. Please be advised that you may be billed for services that your insurance will not cover due to exclusions or plan limitations.
Payment is expected at the time service is rendered. We accept cash, Visa, MasterCard, American express, and Care Credit. Our office does not take any personal checks. If your account has been turned over to our collection agency a 4O% collection fee will be added to your account for the entire balance.
If you break an appointment with our practice, we ask for a 24-hour notice of cancellation. If we do not receive a 24-hour notice, you may be charged a $30 fee for the scheduled appointment. This fee cannot be charged to your insurance company.
I have read and understand the statements outlined above.
I have received and understand this practice's Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information.
I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. lf changes to the policy occur, this practice will provide me with a revised Notice of Privacy Practices upon request.
In order to reduce the risk of spreading COVID 19, please complete a number of screening questions below. For the safety of our team, other patients, and yourself, please be truthful and candid in your answers.
Our practice complies with State Health Department and the CDC infection control guidelines to prevent the spread of the COVID-19 virus; however, we cannot make any guarantees. Our team is screened daily and, to the best of their knowledge, have not been exposed to the virus. We are a place of public accommodation, and other persons (including other patients) could be infected, with or without their knowledge. I hereby knowingly and willingly consent to have dental treatment completed at this time. I will hold harmless and indemnify, the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of COVID-19 National Emergency. I make this decision of my own free will relying upon my knowledge and judgement of any injury I may have sustained or possible transmission of COVID-19 during treatment and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I have carefully read this release and understand its contents, and I am signing it of my own free act.
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 following questions. have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
We understand that you may sometimes need to reschedule appointments. When we make your appointment, please understand that we are reserving time for you to see a provider. This courtesy makes it possible to give the best service here at Dentistry at the Mills. If you need to reschedule an appointment, please call our office as soon as possible or call at least 48 hours in advance.
If you have no showed for your appointment more than 1 time you will be charged a $50 no show fee.
We thank you for your trust here at Dentistry at the Mills.
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