Elliott Bay Dental

Dental Insurance

Dental Information - For the following questions, Please Choose "Yes" or "No" to the following questions.

MEDICAL HISTORY

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 can be dangers 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.

Thank You for choosing Elliott Bay Dental as you dental care provider. Our primary goal is to provide you with the best possible care, without being hindered by the cost of treatment. We will strive to maximize your insurance benefits. Please take your time in reading our Financial Policy. Your clear understanding is important to our professional relationship.

Financial Policy:

Elliott Bay Dental charges what is usual and customary for our area. We will assist you with your benefit eligibility before treatment to help you calculate your costs (Co-Pay) and maximize your insurance. As a courtesy, Elliott Bay Dental will submit the claims necessary so that you receive the full benefits of your coverage, but we cannot guarantee any estimated coverage. Please understand that:

• Payment for a Particular dental service is “ESTIMATED.”
• The estimated Payment for all dental services are DUE AT THE TIME OF SERVICE.
• The Estimated payment may be “subject to change” when the dental service claim is adjudicated by the insurance company.
• Understand your insurance annual benefits. If you or your dependents EXCEED your Annual Benefit Maximum, you will be responsible for the cost of all dental services that exceed your plan’s benefit
• Understand your insurance plan year (not all insurances are from January to December)
• You are responsible for monitoring your REMAINING BENEFITS for the year. Benefits can vary from our records due to use at other offices that we are unaware of.
• The claims we submit to the insurance company indicate that you have assigned those benefits to Elliott Bay Dental. If you are paid by the insurance company, instead of Elliott Bay, then you are responsible for the TOTAL ACCOUNT BALANCE.
• Checks that are returned to our office from your financial institution are subject to a $25.00 returned check fee. This fee covers the processing fees that are charged to our office.

If you have any questions about your insurance, account, co-pays, or any other general financial questions, please do not hesitate to ask. We will gladly help out, and encourage you to contact us promptly for assistance in the management of your account. Most often, financial misunderstandings can be managed with a phone call.

In addition, we offer CareCredit, a patient payment program offering a full range of No Interest and Extended Payment Plans.

Cancellation Policy:

Our doctors and team members spend a significant amount of time to prepare for your dental visit. Broken and missed appointments create scheduling problems for our team, as well as other patients. We understand that life happens, so if you need to change your appointment, we require a notice of at least 48 hours in advance. This allows us to accommodate other patients. If proper notice is not received, a fee of $100 will be charged. Please help us service you better by keeping your appointments.

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.

HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES and CONSENT FORM

We at Elliott Bay Dental are required by law to maintain the privacy of our patients Protected Health Information (PHI). Under the Health Insurance Portability and Accountability Act (HIPAA), you have certain rights regarding the use and disclosure of the protected health information. These rights are more fully detailed in our Notice of Privacy Practices, which is attached to this clipboard. You may obtain a copy of this notice upon request.

We are permitted to review and change our Notice or Privacy Practices at any time. We will provide you with any revisions upon request.

Authorization of PHI Disclosure:

By signing below, I am acknowledging that I have read the Notice of Privacy Practices. I am also giving Elliott Bay Dental consent to use and disclose protected health information to carry out treatment, payment activities, and other healthcare related operations; including, but not limited to specialty care and prescription medication. I am also giving permission to disclose my protected health information to the person(s) listed above.

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.