Consent & Agreements
I give my consent to needed dental services for the patient named below.
I agree to notify this office of any change in the patient's medical history and/or medication.
I understand that the Privacy Policy of this office is posted in the reception room of the office and is available upon request.
I give my consent for this office to send records to another healthcare provider as needed for them to provide care.
Missed Appointment Agreement
I acknowledge an appointment is a reservation.
A 24 hour notice is required to change my appointment. You will not be charged for your first missed appointment. A minimum fee of $25 will be charged for your 2nd missed appointment. Appointments schedule for treatment that requires longer appointment lengths will be charged a higher fee based on lost production time.
Insurance Authorization
I authorize payment of insurance benefits directly to Chattahoochee Valley Dental (CVD).
I authorize the release of all necessary information to my insurance carrier.
Office Payment Policy
I understand that payment is expected at the time of service for all treatment unless prior arrangements have been made.
I understand that CVD files DENTAL insurance claims as a courtesy. I understand that the amount collected at the time of service is an ESTIMATE. I understand that I am responsible for any balance due after my insurance has paid including any and all remaining balance on my account due to policy exclusions or limitations.
I understand that I am responsible for payment of dental serviced provided for the patient named below. Accounts over 30 days past due will be assessed a monthly finance charge equal to 1 ½ % of the unpaid balance (18% annually).
I accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary. I waive now and forever my right of exemption under the laws of the constitution of the State of Alabama and any other State.
In order for CVD to service my account or to collect monies I may owe, I authorize CVD and/or their agents to contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in charges to me by my carrier. I may also be contacted via text messages or emails, using any email address I provide. Methods of contact may include pre-recorded/artificial voice messages and/or use of automatic dialing devices, as applicable.