PATIENT INFORMATION

DENTAL CONCERNS

SPOUSE/GUARDIAN INFORMATION
PERSON RESPONSIBLE FOR ACCOUNT

OTHER DEPENDENTS

EMERGENCY CONTACT

PHYSICIAN INFORMATION

**Please sign to verify the information on this page is correct.**

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

If you have dental insurance, we are happy to help you receive your maximum allowable benefits and are pleased to bill your insurance directly. Some insurance companies select certain services they will not cover. The manner in which usual and customary fees are determined may vary from policy to policy. Any balance owed after insurance payment will be the patients responsibility.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

PATIENT INFORMATION

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

If you have dental insurance, we are happy to help you receive your maximum allowable benefits. In order to achieve this goal we need your assistance and your understanding of our payment policy.

• We need you to provide us with updated/current insurance information

You will be asked to update your personal and insurance information periodically, including providing our office with copies of your insurance card. We are required by law to obtain your signature for permission to release information to your insurance carrier. Please assist us in complying with your insurance requirements.

• The treatment plan we propose is an estimation based on the information provided by your insurance company.

Verification of your insurance is not a guarantee of payment. Amounts due by you (the patient/guarantor), are based on what has been quoted to us via fax, phone, or online services, and is not necessarily your entire balance. Your insurance company determines payment, according to the policy you have chosen and the contract your employer has with them when the claim is received. Every effort is made by this office to submit accurate information to your insurance company.

• Outstanding balances are due immediately regardless of any insurance appeals/discrepancies

If you do not agree with the way your insurance company has paid your claim, have any questions regarding claim payment, or payment has not been made, please contact your insurance company for explanation. Existing balances on your account must be paid in full prior to receiving additional services even if you are appealing or questioning claims payment. If additional payment is received causing credit on your account a refund will be made to you.

• Our relationship is with you, not your insurance company

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. All though we may be have fee negotiations with your insurance company, we must emphasize that as a dental care provider, our relationship is with you, not your insurance company.

• Payment is due at time of appointment

Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. While the filing of insurance claims is a courtesy that we extend to patients, all charges are your responsibility from the date the services are rendered. Payment for services, including insurance co-payment or self-pay balance amount, is due at the time services are rendered unless payment arrangements have been approved in advance by the Office Manager.

Signature

NOTE: By my signature below I agree to the terms of the Statement of Payment Policy.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

If you are unable to keep your scheduled appointment, please call 360-687-0909 to let us know.

If an appointment is missed or cancelled without 48 hour notice (excluding weekends and holidays) you will be charged. A minimum of $100 per hour will be charged, the charge may be higher depending on the scheduled appointment. Missed appointments are NOT covered by insurance. If you miss three appointments within a rolling 12 month period for reasons not accepted by Above & Beyond Dentistry as out of your control, you will no longer be eligible to receive care from our office.

As a courtesy, appointment reminder text messages are sent and if not confirmed by text you will then receive a phone call. Please provide us with the best possible contact number so we may contact you in regards to your appointment.

Exceptions to the charge are made on a case-by-case basis.

Your signature serves as acknowledgement that you have been informed of this policy. If the patient is a minor, the parent and/or guardian is responsible for the charge.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

We keep a record of the health care services we provide you. You may request to see these records and request copies. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so, as noted in our privacy policies. You may see your record or get more information about these privacy policies (HIPPA) by contacting the manager of Dr Low’s office/Above & Beyond Dentistry & Implants.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

I would like my appointment reminders to be sent via:

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.