Patient Demographic Information

DENTAL INSURANCE INFORMATION

I am not covered by any Dental Insurance at this time

I hereby authorize Provider, or his staff to release any and all medical and dental information pertinent to my treatment to the above named insurance carriers for the purposes of preauthorization of treatment plan and fees, claims processing, utilization review or financial audit. In addition, I hereby authorize insurance payment directly to Provider1 of the medical and dental benefits otherwise payable to me, for the services rendered to me by either doctors or their staff. I have been informed that this office will report my diagnosis, treatment and fees to my carriers in accord with standards conforming to the current procedures established by the American Academy of Periodontology, and that it is the sole power and responsibility of my carriers to determine the actual dollar amounts of benefits for all services rendered. I understand that I am ultimately responsible for the total costs of my treatment provided by Provider2.

Cancellation Policy: There will be a substantial charge if a surgical treatment appointment is canceled with less than 3 working days notice. All other appointments require 1 full working day’s notice for any change. Hygiene appointment changes require 24 hr. notice to avoid a cancellation fee. Please remember this time is reserved exclusively for you. Your courtesy in doing this may allow someone else to be seen in a timelier manner.

Payment: There is a 5% discount for full payment by cash or check at the time service is rendered for treatment over $1000.00. Full payment by credit card receives a 2% discount under the same conditions. We request that all balances be paid in full within 90 days of treatment, unless specific financial arrangements are made before treatment.

I acknowledge that I have read and understand the above statements and policies, and that this authorization remains valid and effective from the date of signing until revoked in writing.