New Patient Form

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure if your protected health information to carry out treatment, payment activities, and healthcare operations.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of treatment, payment, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice Accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in out Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will include the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notices of Privacy Practices, including any revisions of our Notices, at any time by contacting:

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue to treat you if you revoke this Consent.

Thank You for selecting us as your dental health care provider

• Full payment is due at the time of service unless other arrangements have been made. We graciously accept Cash, Checks, Visa, MasterCard, Discover and American Express
• For Patients with comprehensive treatment plans, we offer a definitive payment plan for 3 months with no interest
• We offer extended payment plans with prior credit approval by outside lending organizations such as:
  • Fifth Third: 12 months interest free; with no processing fee.
  • Care Credit: 12-18 months interest free, with a processing fee that will be calculated to 7% your total comprehensive treatment plan.

Your insurance policy is a contract between you and your insurance company. It is important to know that professional services are rendered and charged to you, the patient. Because different insurance companies reimburse the office at their own “Usual and Customary Fee” rates, there will be an In-Office co-pay for each visit of treatment to you, the patient. Should your total treatment be covered under your plan, our office will reimburse you, or add a credit to your account after the Insurance Coverage has been received.

Minor Patients
The parent or guardian accompanying a minor is responsible for the full payment regardless of any insurance coverage through a divorced parent situation. For unaccompanied minors, non- emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa, MasterCard, Discover, or payment by Cash or Check at the time of service.

I have read, understand, and agree to the provisions of these Benefit Options. In the event of defaults in the payment of arrangements made, and if these arrangements are placed in the hands of an attorney at law for collection, the undersigned hereby agrees to pay all costs of collection including a reasonable attorney’s fee. Presentment protest and notice are hereby waived.