Health History

In the following questions, select yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

We are committed to provide you the best possible cares. If you have a dental insurance policy, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and understanding of our payment policy.

Payment for services is due at the time services are rendered. We accept cash, checks, American Express, Discover, Mastercard, Visa or Care Credit. We will be happy to process your insurance and in many instances can accept assignment of insurance benefits directly to our office. Should your insurance not assign benefits to our office, you will be responsible for full payment at the time of services and we will happy to process your insurance claim-form for your reimbursement.

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. We can only per-estimate your co-payment based on the perception of your policy.
2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50% or 80%) of "U.C.R" is defined as usual, customary and reasonable fees for the region. Thus, our fees are considered usual, customary and reasonable by most companies.
   This statement does not apply to companies who reimburse based an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in this area.
3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

We must emphasize that as dental care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we gladly extend to our patients, all charges are your responsibility from the date the service are rendered. We realize temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Note:

Returned Checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1¹⁄₂% per month. We do not accept out of town checks. Charges may also be incurred for broken appointments and appointments cancelled without a 24 hour notice.

I have read and understand above stated financial arrangements and insurance policies.

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