New Patient Information

CHILD SCHOOL

MOTHER

FATHER

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

CONSENT AND AUTHORIZATION

By my signature below, I authorize the following: 1) Release of any information including the diagnosis, records of treatment, or examination rendered by my child during the period of dental care, to third-party payers and health practitioners. 2) Use of this signature on all insurance claim submissions. 3) Payment directly to the dentist of all insurance benefits otherwise payable to me for services rendered. 4) I understand that my dental insurance carrier may pay less than the actual bill for services rendered and that I am financially responsible for all charges whether or not paid or covered by my insurance company.

EMERGENCY CONTACT

CHILD'S MEDICAL & DENTAL HISTORY

If any allergy, always carry emergency drugs

Consent & Authorization

By my signature below, I authorize dental treatment for my child and understand the following:

• To the best of my knowledge, the above information is accurate, and will not hold Dr. Skordalakis, DDS, or his team members responsible for any errors or omissions made while completing this form.
• Providing incorrect information is dangerous to my child’s health and safety, and it is my responsibility to inform Dr. Skordalakis or his team members when there is a change in my child’s medical condition, or when there is a change in the responses to any of the above questions.

Person Legally Responsible for Child

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.

OFFICE POLICIES, PATIENT & FAMILY RESPONSIBILITIES

Patients with insurance coverage: As a courtesy, a claim is filed with your dental insurance company using information you provide us. Therefore, you must provide accurate information; a fee is charged for resubmitting a claim when incorrect information is provided. Insurance has limitations, restrictions and partial coverage for most dental services; example: fluoride treatment, sealant, resin/white filling, crown. Without exceptions, payment is required at the time of service for patient portion – deductible, co-pay amounts. Please note that we can only estimate the patient portion – it is not the exact amount you owe. The exact patient portion will be known only after the claim is processed by your insurance, and a statement is then mailed to you for any balance amount.

Patients without insurance coverage: Treatment plan with estimate of fees is provided prior to starting dental treatment. Without exceptions, full payment is required at the time of service.

Minor patients: Both parents or guardians are financially responsible for full payment at the time of visit. In the case of divorced or separated parents, both parents are responsible for full payment, without any exceptions.

Payment methods: Cash, check, debit, and credit cards: MasterCard and Visa, Discover and American Express.

Returned checks: $40.00 charge applies when a check is returned by the bank due to insufficient funds.

Finance charge: After a dental claim is processed by insurance, a statement is mailed to the address on record for the remaining balance. Payment is expected within 25 days of the statement date, to avoid 1.5% monthly finance charge

Refunds: An account with a credit balance is issued a refund check in the name of the person shown under “Financial Responsibility for account” and mailed to the address on file. You may choose to keep the credit balance in our office for use towards future dental care.

Missed Appointments-24 hour notice needed: To reschedule an appointment, our office must be notified at least twenty four (24) hours in advance.

Termination of Treatment Our office reserves the right to cancel future appointments and terminate professional relationship for any of these reasons:

• When scheduled appointments are not kept,
• When patient arrives late to scheduled appointments causing inconvenience to other patients
• Uncollected debt owed (past due account) to this office.

American Credit Bureau: Our accounting department promptly reports past due and delinquent accounts to the national credit bureaus – Equifax, Experian, and Trans Union.

Financial Responsibility Agreement By signing this document, I understand and agree to the following:

1. I am responsible for payment of all charges for services rendered, regardless of insurance coverage.
2. Unpaid balance for more than 30 days after services are rendered is subject to interest of 18% per annum.
3. An unpaid balance over 60 days is reported to the American Credit Bureau. The debt owed to this office will appear on my permanent credit file at the nation’s leading credit bureaus – Equifax, Experian, and Trans Union. To collect the debt, such an account may also be sent to an attorney or collections agency and I agree to pay 33.3% of attorney’s fees, all court costs, and fees associated with the collection efforts.

Consent & Authorization By my signature below, I authorize dental treatment for my child and understand the following:

• To the best of my knowledge the above information is accurate, and will not hold Dr. Skordalakis, DDS, or his team members responsible for any errors or omissions made while completing this form.
• Providing incorrect information is dangerous to my child’s health and safety, and it is my responsibility to inform Dr. Skordalakis or his team members when there is a change in my child’s medical condition, or when there is a change in the responses to any of the above questions.

Person Legally Responsible for Child

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.

ACKNOWLEDGEMENT STATEMENT OF PRIVACY PRACTICES

I acknowledge that I have received the Statement of Privacy Practices (“Statement”) for the office of Dr. Skordalakis, DDS, PC. The Statement describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. Also, it describes my rights and the responsibilities and duties of the office with respect to my protected health information. The Statement is posted in the facility.
Dr. Skordalakis, DDS, PC reserves the right to change the privacy practices that are described in the Statement. If privacy practices change, I will be offered a copy of the revised Statement at the time of my first visit after the revisions become effective.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described at the front desk, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below

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.