Authorization and Release:
I authorize Douglass Family Dentistry to release any/all information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or other health practitioners.
Upon request of Douglass Family Dental to file my insurance, I authorize and request my insurance company to pay directly to the dentist (or dental group) insurance benefits otherwise directly payable to me.
FINANCIAL AGREEMENT FORM
This is an agreement between Douglass Family Dentistry (Dr. James D Douglass DDS Inc) as a creditor, and the Patient/Debtor.
In this agreement the words “you”, “your” and “yours” refer to the Patient/Debtor. The word “account” refers to the account that has been established in your name which charges are made and paymentscredited. The words “we,” “us” and “our” refer to Douglass Family Dentistry.
By executing this agreement, you are agreeing to pay for all services that are rendered and those services rendered in connection to the service.
Monthly Statement: You will receive a monthly statement unless insurance is pending, there is a zero balance or account has been turned over to ollections. It will show separately the previous balance, any new charges to the account and any payments or credits applied to your account during the month.
Missed appointment policy:
Payments: Unless other agreed upon arrangements are made, the balance on your statement is due and payable when the statement is issued, and is past due if not paid within 30 days.
Charges to Account: We reserve the right to cancel your privilege to make charges against your account at any time.
Insurance: Insurance is a contract between you and your insurance company. YOU ARE RESPONSIBLE FOR ANY AMOUNT DUE AFTER THE INSURANCE REIMBURSEMENT, REGARDLESS OR THE OFFICE ESTIMATE. Your insurance company will be billed as a courtesy. WE CAN ONLY ESTIMATE WHAT YOUR INSURANCE COMPANY MAY PAY. It is the insurance company that makes the final determination for your eligibility. YOU ARE LIABLE FOR ANY PORTION FO CHARGES NOT COVERED BY YOUR INSURANCE. If your insurance company requires a referral and/or pre-authorization, you are responsible for obtaining it and failure to obtain the referral and/or pre-authorization may result in a lower payment from the insurance company.
Required payments: Co-payments (estimated) required by your insurance company must be paid before service is rendered.
Returned checks: There is a fee [subject to change] for any returned check(s). Post-dated checks are not accepted.
Refunds: If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care you received. In the case of discontinuing treatment with lab cases, you will only be responsible for lab fees and cost of materials. If you have a credit balance at the conclusion oftreatment, we will send a statement of credit to the address on file and you may request an immediate refund of any amount due.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this amount due. If your account is referred to a collection agency/ lawyer you are liable for all collection costs and/or fees that are incurred. Any account balance on which payment has not been made for 3months (from the time of initial statement) may be turned over for collections. Previous unpaid balances must be paid prior to service unless prior arrangements have been made.
Waiver of confidentiality: In general, a health care provider may disclose protected health information as necessary in a legal proceeding without an individual's consent or authorization if disclosure isrequired by law and the disclosure complies with the requirements of the law.
Divorce: In the event of divorce or legal separation, the party responsible (if not the patient) remains responsible for payment of the account. In the event of a divorce of legal separation, the parent authorizing treatment for a child will be the individual liable for subsequent charges in relation to the rendered services.
Co-signture: If this document is co-signed, those individuals are equally responsible for all services rendered until a subsequent arrangement, if any is rendered with this office. If written cancellation is received, it becomes effective upon receipt in regard to any future services.
Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect at that time.
By signing the following, I acknowledge that I have read and agree to the terms within:
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
You as patient have the following rights:
This policy goes into effect as of April 14, 2003.