Thank you for choosing Smile Station as your dental provider. We are committed to providing excellent care for all your dental needs. We want you to be aware of our expectations concerning the financial aspect of your visit. Please sign this form after
you have read it through completely.
**All patients must complete our health history, insurance and HIPAA forms before seeing the doctor.
**Co-payments or partial payments are due at the time of the service. Smile Station Pediatric Dentistry charges $35.00
for returned checks.
**We accept, cash, checks, credit cards and Care Credit.
**We will provide an estimate for your dental work upon request.
A fee of $25.00 may be charged for patients who miss or cancel more than 1 time in a calendar year without 24-hour notice. Repeated missed appointments may result in dismissal from our practice.
We are not responsible for how individual policies are processed and paid other than those companies we are contracted with. It is a contract between you, your employer and the insurance company. If you have questions about your benefits or how your
claims will be paid, you need to contact your insurance company. We will assist you with questions if we are able. We cannot bill your insurance company unless you give us the correct insurance information. Any account sent to a collection agency will
be assessed and additional service fees and you will bear the cost of collection and or court costs and reasonable legal fees, should this be required.
Usual & Customary Rates
We are committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
The adult accompanying a minor, and the parents (or guardians of the minor) are responsible for payment. Co-pays or percentages of the total payment are due at the time of service.
This office is not a party to your divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for minors rests on the accompanying adult.
Please let us know if there are any areas of the policy that are unclear or if you have additional questions.
I authorize the release of any information relating to dental claims and authorize payment directly to Smile Station
Consent for Services
I give my consent to the attending dentist to render to me the dental treatment that we have agreed is necessary for myself.
I HAVE READ, UNDERSTAND AND ACCEPT THE ABOVE POLICIES OF THIS OFFICE.
Acknowledgement of Privacy Practices
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
1. Provide and coordinate my treatment among a number of health care providers who may be involved in the Treatment directly and indirectly.
2. Obtain payment from third-party payers for my health care services.
3. Conduct normal health care operations such as quality assessment and improvement activities
I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.