Patient Information Form - Stony Creek Dentistry (Page 3 of 3) in pdf

Practice Information and Policies

Patient Information: A fully completed, current patient information registration will be on file in your chart and in our

computer during all times the patient is considered active in our practice. Patients are required to inform this office of any changes

in their Medical or Dental Health since their last visit and to keep us up-to-date on an annual basis.

Treatment Cost - Nobody likes to be surprised when it comes to costs. Our policy is to inform you of what your investment will

be prior to any treatment. We will review with you our recommended treatment plan and its cost. To make getting a beautiful new

smile as easy as possible, we offer several convenient payment methods. Our staff is available to discuss financial arrangements

and help you select the method of payment that best meets your needs.

Insurance Benefits: Please note that your dental insurance policy is a contract between you and your insurance company. We

will be happy to assist you in completing and submitting copies of your insurance paperwork to your provider. At your first visit,

please bring your insurance card so we may enter the appropriate information into your computerized patient file. We request that

you also keep us updated as to any changes in your insurance coverage. Our staff members will be happy to assist you with any

questions you may have about insurance, but the ultimate financial responsibility for dental services will be that of the patient, not

the insurance company.

Secondary Insurance: We will accept Secondary dental insurance, but secondary insurance is often difficult to work with. As a

courtesy, we will file secondary dental insurance for patients upon submission of proof of secondary insurance. However, if

payment is not received in our office within 60 days of the service, the responsibility will be transferred to the patient, and the total

outstanding balance will be due from the patient at that time.

Patient Financial Responsibility: It is the sole responsibility of the patient to insure that our practice accepts their insurance

or is in their network. If we are not a provider, then payment in full will be expected at the time of service. All dental insurance co-

payments, deductibles, non covered services and amounts above usual and customary as determined by your insurance company

are due at the time of service.

Finance Charges: Any amount your insurance does not cover (deductibles, co-payments, or amounts above usual and

customary as determined by your insurance company) will be due at the time of your service. We offer several convenient

payment methods, but do not send monthly statements or accept monthly in-office payment plans. There will be a 1.5% finance

charge per month on any balance due over 30 days.

Methods of Payment: Acceptable methods of payment are cash, check, MasterCard or Visa. Additionally, we offer several no

interest payment and financing plans through outside financing companies like CareCredit.

On-time Appointments: We work hard to keep on-schedule and our patients rarely have to wait for their appointment or to

see the doctor. We understand that our patients have busy lives and dental appointments are just a small part, but in order to help

us keep our schedule it is very important for you to be on time for your appointment.

Missed Appointment: We understand that emergencies do arise, but if you must cancel your dental appointment we need at

least 24 hours notice. Appointments missed and not previously cancelled will be charged a $25 “no show” fee for routine visits.

After two “no show” appointments you may be dismissed from the practice.

10. Dental Emergencies: If you have a dental emergency during non-business hours you may leave a message on the answering

machine. There will be an emergency number on our answering machine that you may call to reach one of the doctors. Please

understand that you may need to leave a message on the doctor’s private number with your name and phone number.

11.

Estimates of Charges: If you are recommended to return for dental treatment we will provide you with a treatment plan and an

estimate of what your insurance may or may not cover. Due to the nature of dental care and unforeseen problems that arise during

treatment, this is only an estimate and the treatment and fees may change. In the event that your insurance pay less than the

amount estimated, you are responsible for the unpaid balance.

12. Delinquent Accounts: Accounts that become past due over 90 days are considered delinquent and will be automatically turned

over to a collection agency or our attorney. This may result in court action, adverse credit rating reporting and additional penalties

and fees. In the event an account becomes delinquent, the undersigned understands that future treatment may be delayed and that

the patient or responsible party will be responsible for attorney fees, collection agency fees, cost of collections, court cost and/or

other expenses and fees necessary to collect the unpaid balance.

13. Contacting Patients and Release of Information: The undersigned grants Family Dental P.C. , Stony Creek Dental P.C., its

doctors, staff and its assignees the right to telephone them or their contact person at home or work to discuss any matters related

to this form. In order to submit claims to your dental insurance or other healthcare providers, we must have your authorization to

release these medical/dental records and information. Your signature below authorizes the release of this information.

14. Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191: We are required by applicable

federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our

privacy practices, our legal duties and your rights. This information, in detail, is available at the front desk and is posted in our

waiting room. Please take time to read and understand your rights under HIPAA. If you would like an additional copy of our

HIPAA form please ask us and we will make one available to you.

I have read and understand the above information and practice polices for Family Dental P.C. and Stony Creek Dentistry.

Print Name: _____________________________ Patient Signature: _______________________________ Date: _________

Patient Information Form - Stony Creek Dentistry Page 3

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