I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Dental care to third party and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.
PAYMENT IS DUE WHEN SERVICES ARE RENDERED. We accept cash, personal checks, Mastercard, Visa, Discover, and American Express. As we are providers for Altus, Blue Cross/Blue Shield of MASS, Cigna, United Concordia Elite and Delta Dental (excluding Delta Care, Tufts, Delta and Delta's PPO), we will submit claims for payment and ask you for an estimated co-payment at the time services are provided. For all other insurance coverage, we ask for full payment at the date of service and will submit a claim for reimbursement too you. We realize that some procedures are more extensive than others and we will be willing to work out altenative financial arrangements prior to treatment. Please see our billing manager regarding this.
PAYMENT IS DUE WHEN SERVICES ARE RENDERED. We accept cash, personal checks, Mastercard, Visa. Discover, and American Express. As we are providers for Blue Cross / Blue Shield of Mass. Delta Dental Plan (excluding Delta Care, Tufts Dental. Delta's PPO Cigna. United Concordia Elite and Altus Dental, we will submit claims for payment and ask you for an estimated co-payment at the time sérvices are provided. For all other insurance coverage. we ask for full payment at the date of service and will submit a claim for reimbursement to you. We realize that some procedures are more extensive than others and we will be willing to work out alternative financial arrangements prior to treatment. Please see our billing manager regarding this. In the case of a divorce. the parent bringing the child to the office will be deemed financially responsible.
I have read the above and understand my obligations.
I authorize my insurance company(s) to pay benefits directly to my dentist. I understand that all policies are different and am responsible for knowing my plan provisions. I understand that I will be responsible for all copayment, deductible, and rejected charges.
At Natick Dental Partners, we understand that you may need to change your existing appointment in our office. If an appointment needs to be canceled and/or rescheduled, we ask you to provide our office
with at least 48-hour notice. This will allow our staff to fill the schedule with another patient who may be waiting for this appointment time.
If we receive less that 48-hours notice, a fee equal to the length of your appointment will be charged to
your account (i.e. a 45 minute appointment = $45.00 This same fee will also be assessed if you miss an
appointment. We do understand and will take into account extenuating circumstances.
Our intent is not to penalize our patients, but to help us provide proper staffing to better meet the
After reviewing our policy, please sign the agreement below.
I have reviewed and understand Natick Dental Partners' Late Cancellation and Missed Appointment Policy.
After a thorough comprehensive examination, Natick Dental Partners may recommend a restorative procedure (filling) or several restorative procedures (fillings) for you or your child.
We no longer use silver (amalgam) fillings on primary (baby) teeth due to the substantial improvement in composite/resin (white) filling materials. These new materials have been found to perform better than the amalgam restorations on primary teeth. (We may still recommend, on occasion, silver (amalgam) fillings in certain cases for permanent (adult) molars Please be aware that if your insurance policy does not cover composite/resin fillings, your co-payment will be higher. The balance is the patient's
Please contact your insurance company for further explanation.
All policies are different and it is very important, if finances are a concern, to file a pretreatment estimate with your insurance company for the treatment plan recommended. We will be happy to
do that for you at your request.
In every case Natick Dental Partners will make a recommendation as to the material to use that is in your best interest. Please discuss the treatment beforehand if you have a concern about the
recommendation made. We welcome your input.