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Section Two

Referred by / Phone

Dentist Name / Phone

Physician Name / Phone

Pharmacy Name / Phone

Emergency Contact

Name / Phone / Relationship

Guarantor

(Person financially responsible for account) must sign the Financial and Payment Policy Form.
Please Note: Patients under the age of 18 cannot be responsible for their own account.

Patient Relationship

Spouse Child Parent Other

Name

Home Address

City / State / Zip

Phone Numbers

Birth Date

Driver's License # / Email

Primary Dental Insurance Information

Insurance Co. Name

Phone Number

Employer Name

Group # / Ins. ID #

(may be SSN of policy holder)

Claims Address

City / State / Zip

Policyholder's Name

Relation to Patient

Date of Birth

Home Address

City / State / Zip

Phone Number

Secondary Dental Insurance Information

Insurance Co. Name

Phone Number

Employer Name

Group # / Ins. ID #

(may be SSN of policy holder)

Claims Address

City / State / Zip

Policyholder's Name

Relation to Patient

Date of Birth

Home Address

City / State / Zip

Phone Number

Primary Medical Insurance

Insurance Co. Name

Phone Number

Employer Name

Group # / Ins. ID #

(may be SSN of policy holder)

Claims Address

City / State / Zip

Policyholder's Name

Relation to Patient

Date of Birth

Home Address

City / State / Zip

Phone Number

Secondary Medical Insurance

Insurance Co. Name

Phone Number

Employer Name

Group # / Ins. ID #

(may be SSN of policy holder)

Claims Address

City / State / Zip

Policyholder's Name

Relation to Patient

Date of Birth

Home Address

City / State / Zip

Phone Number

Insurance Agreements

I authorize release to my insurance company of any information relating to a claim

Yes No

I hereby authorize payment directly to my dentist of the insurance benefits otherwise payable to me

Yes No

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or in the above information. This information will be kept confidential. I am aware that a copy of my insurance card(s) will be made available, and a copy kept in my records. I am responsible for updating this information if and when there are changes.

Printed Name / Relation to patient

Signature

Click to Sign

Date:-------------

AFFIDAVIT AS TO THE TRUTH OF MY MEDICAL HISTORY

I have answered all the above questions and have indicated YES or NO in the proper places to the best of my knowledge. I certify that all answers are truthful and understand that false answers, or errors in answering, could jeopardize my care and my health.

SIGNATURE

Click to Sign

Date:-------------

If the patient is unable to read or understand these records and another person has filled them out, the name of that person is:

SIGNATURE OF INTERPRETER

Click to Sign

Date:-------------

WITNESS

Click to Sign

Date:-------------

Financial And Payment Policy

Thank you for choosing us to deliver your oral surgery care. We feel that everyone benefits when there is a definitive and clear financial agreement prior to treatment. You can help by paying for treatment rendered upon completion of each visit. To make your financial arrangement as easy as possible, we accept the following methods of payment: Cash, Check, Visa, MasterCard, Discover, American Express, or Care Credit.

After being evaluated by the Surgeon, you may request an estimate for any procedure charges prior to having treatment.

Please choose one of the following payment options.

Yes No

INSURANCE: Dental- We participate with Delta Dental.

The financial obligations for the treatment we render to you are your responsibility. The patient is responsible to the doctor and the insurance company is responsible to the patient. If your insurance covers your procedure, we will submit to participating insurance companies for covered services. If benefits cannot be determined at the appointment time, you will be considered a self-pay patient and payment in full will be due at the appointment time. As a courtesy, benefits are verified but are not a guarantee of payment/coverage. All claims are subject to review by your insurance company. A traditional insurance plan pays a percentage of your charges up to your maximum benefit. The percentage (co-pay plus any deductible) you are responsible for plus any amount over your yearly maximum will be due and collected the day of treatment. If your insurance carrier denies payment or delays payment beyond 28 days, a .05% finance charge will be applied to your account after 28 days and YOU are then responsible for any remaining balance. It is your responsibility to know your insurance coverage prior to your appointment.

Yes No

Option 2 Payment In Full

is due the day of treatment. Self-pay patients (no insurance/Option 1) with charges over $1,000 who make full payment the day of service by cash or check will receive a 5% discount.

Yes No

Option 3 Easy Pay (for patients without insurance coverage) -

If you do not have insurance coverage, divided payments for any amount (guaranteed by a credit card) can be arranged with half (50%) of the total fee due at the time of service. Payments for implants may also be divided. The remaining balance will be billed directly to your credit card 30 days from the date of service. You are authorizing us to charge your card the balance up to 15 days AFTER the balance charge date if required.

Yes No

Option 4 CARE CREDIT

is for patients that require payment plans beyond 30 days. Care Credit requires an application and credit approval. Payment is made by you directly to Care Credit. Our office offers either 6 months with 0% APR or extended plans of 24,36 and 48 months with a minimum balance of $1000 at 14.9% and 60 months with a minimum balance of $2500 at 16.9% APR.

This signature is my agreement to the payment policy I have chosen above. I accept full financial responsibility for all charges incurred. I understand that I will be apprised of my account status every 28 days and finance charges will accrue every 28 days of non-payment at the rate of .005. If this account is placed into a collection agency, an additional collection fee, based off the account balance, will be added to this account. Collection fees are as follows: a collection fee of $75 will apply to overdue balances between $50.00 and $250.00, a fee of $125 will apply to overdue balances between $251.00 and $500.00, a fee of $200 will apply to overdue account balances between $501.00 and $750.00, a fee of $250 will apply to overdue account balances between $751.00 and $1000.00, and a fee of $300.00 will apply to overdue account balances $1001.00 and higher. Please note that the person who signs this form is considered the responsible party for this account. Patients under the age of 18 cannot be responsible for their own account.

Signature

Click to Sign

Date:-------------

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Main Header

Demographic Information

Patient information

Section Two

Emergency Contact

Guarantor

Dental Insurance

Primary Dental Insurance Information

Secondary Dental Insurance Information

Primary Medical Insurance

Secondary Medical Insurance

Insurance Agreements

Click to Sign

Medical History

Medical History

Health History

Do you have or have you ever had any of the following?

Patients having intravenous sedation or general (sleep) anesthesia answer the following

AFFIDAVIT AS TO THE TRUTH OF MY MEDICAL HISTORY

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Financial And Payment Policy

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HIPAA Acknowledgement & Consent

HIPAA PATIENT ACKNOWLEDGEMENT AND CONSENT

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Main Header

Demographic Information

Patient information

Section Two

Emergency Contact

Guarantor

Dental Insurance

Primary Dental Insurance Information

Secondary Dental Insurance Information

Primary Medical Insurance

Secondary Medical Insurance

Insurance Agreements

Click to Sign

Medical History

Medical History

Health History

Do you have or have you ever had any of the following?

Patients having intravenous sedation or general (sleep) anesthesia answer the following

AFFIDAVIT AS TO THE TRUTH OF MY MEDICAL HISTORY

Click to Sign

Click to Sign

Click to Sign

Financial And Payment Policy

Click to Sign

HIPAA Acknowledgement & Consent

HIPAA PATIENT ACKNOWLEDGEMENT AND CONSENT

Click to Sign

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