Daniel Castro D.D.S, P.A 6901 Helen of Troy, BLDG. C El Paso, Texas, 79911 915-581-8070
Daniel Castro D.D.S, P.A
6901 Helen of Troy, BLDG. C
El Paso, Texas, 79911
915-581-8070
THE RULES AND REGULATIONS OF THE STATE OF TEXAS REQUIRES US TO KEEP ALL PATIENT RECORDS FOR 5 YEARS. PLEASE BE ADVISED SHOULD YOU RELOCATE AND NEED A COPY OF YOUR X-RAYS THERE WILL BE A DUPLICATION FEE OF $15 to $25 (RULE 108 SECTION G OF THE STATE BOARD OF DENTAL EXAMINERS), ALLOW TWO WEEKS FOR DUPLICATION.
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To receive treatment in this office you must answer all questions on this history form. The questions asked relate directly to the safe and effective treatment you are to receive in the office‐to the best of your ability honest answers must be given. If you are unsure of the questions, unsure of your answer, or whether the questions relate to your medical condition, you are to discuss the matter with the doctor. Some of the questions may not relate to your medical condition; in the event you are to write “N/A” (not applicable) in the space provided. All questions must be answered. To properly evaluate your current health status it may be necessary for the dentist to contact your physician. Included on this form is “Permission to Release Information.”Please sign it in the presence of a member of the office staff. ALL INFORMATIONS YOU SUPPLY ON THIS FORM OR INFORMATION OBTAINED BY YOUR PHYSICIAN AND THE SUBSEQUENT INTERVIEW BY THE DENTIST WILL BE HELD IN THE STRICTEST CONFIDENCE, AND WILL NOT BE DISCLOSED WITHOUT YOUR WRITTEN PERMISSION.
YOU WILL BE GIVEN AN "ESTIMATED" PORTION FOR YOUR DENTAL TREATMENT THAT IS NEEDED, THIS IS ONLY AN ESTIMATE. SOME TEETH MAY HAVE HIDDEN DECAY, OR AFFECTED NERVES, REQUIREING MORE EXTENSIVE DENTAL TREATMENT AND ADDITIONAL COST. PAYMENT IS DUE AT THE TIME OF SERVICE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. IF FOR SOME REASON MY ACCOUNT SHOULD BECOME DELINQUENT (AFTER 30 DAYS) I AGREE TO PAY THE INTEREST CHARGE OF 18% ON THE UNPAID BALANCE IN THE EVENT OF DEFAULT, I AGREE TO PAY ALL COSTS OF COLLECTION AND ATTORNEY'S FEES.
WE WILL ASSIST OUR PATIENTS WHO HAVE INSURANCE BY FlLING THE NECESSARY FORMS. PLEASE BE ADVISED YOUR INSURANCE COMPANY WILL PAY A PERCENTAGE OF OUR FEES AS DETERMINED BY YOUR INSURANCE COMPANY (REFERRED TO AS USUAL, CUSTOMARY, AND REASONABLE FEES). NOT NECESSARILY THE ACTUAL FEE CHARGED BY DR. CASTRO. YOU WILL BE RESPONSIBLE FOR THE DIFFERENCE BETWEEN DR. CASTRO'S FEES AND THE FEE "SUGGESTED" BY YOUR lNSURANCE COMPANY SHOULD THERE BE ONE.
DR. CASTRO IS ONLY A LISTED PROVIDER FOR SOME OF THE FOLLOWING INSURANCE PLANS: HUMANA, GUARDIAN (AETNA AND UNITED HEALTH), CIGNA (GEHA) AND UNITED CONCORDIA ALLIANCE (SUN LIFE). OTHER INSURANCES WHERE YOU HAVE THE "FREEDOM OF CHOICE" WE WOULD GLADLY SEE YOU AND BILL YOUR INSURANCE AS WITH ANY INSUARNCE PLAN WE CAN NEVER GUARANTEE EXACT PAYMENT. ULTIMATELY YOU ARE RESPONSIBLE FOR ANY UNPAID BALANCE AFTER YOUR INSURANCE PAYMENT HAS BEEN RECEIVED BASED ON OUR FEE, NOT NECESSARILY THE AMOUNT PAID BY YOUR INSURANCE.
I HEREBY GIVE AUTHORIZATION FOR PAYMENT OF INSURANCE BENEFITS (AS LONG AS I AM A PATIENT OF RECORD) BE MADE DIRECTLY TO DANIEL CASTRO, DDS FOR DENTAL SERVICES RENDEDED. I UNDERSTAND THAT I AM FINANCIAILLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT THEY ARE COVERED BY INSURANCE. OUR OFFICE FILES YOUR lNSURANCE AS A COURTESY TO ALL OUR PATIENTS AT NO CHARGE. IF AFTER 30 DAYS WE ARE UNABLE TO COLLECT FROM THEM IT WILL BE YOUR RESPONSIBILITY TO CORRESPOND WITH YOUR INSURANCE COMPANY IN AN ATTEMPT OF PAYMENT. I HEREBY AUTHORlZE MY DENTAL CARE PROVIDER TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS.
IT IS OUR OFFICE POLICY THAT WE RECEIVE A TWO BUSINESS DAY CANCELLATION NOTICE FOR ANY SCHEDULED DENTAL APPOINTMENT THAT A PATIENT IS UNABLE TO KEEP. THIS WILL ALLOW US TO RESCHEDULE YOUR APPOINTMENT AND LET ANOTHER PATIENT HAVE THE APPOINTMENT TIME ORIGINALLY RESERVED FOR YOU. WE REQUEST THIS COURTESY BECAUSE IT ALLOWS US TO SEE OUR PATIENTS PROMPTLY. IT ALSO HELPS US PROVIDE MORE AFFORDABLE DENTAL CARE FOR ALL OF OUR PATIENTS. IF YOU FAIL AN APPOINTMENT OR ARE ROUTINELY LATE YOU MAY BE DISMISSED FROM OUR DENTAL PRACTICE AN APPOINTMENT IS CONSIDERED FAILED WHEN WE DO NOT RECEIVE A TWO BUSINESS DAY CANCELLATION NOTICE AND THERE MAY BE A $50 CHARGE.
I have read this office's Notice of Privacy Practices attached to clip board.
Our office attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained for the following reason: