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  • NEW PATIENT REGISTRATION PACKET

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  • FOR MINOR PATIENTS

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  • EMERGENCY CONTACTS

  • BILLING, CREDIT, AND INSURANCE INFORMATION

  • EMPLOYMENT INFORMATION

  • INSURANCE INFORMATION

    Complete Only if You Have Dental Insurance.
  • Please read the following Chandler Family Dentistry policy and acknowledge your acceptance by signing below. As your dental care provider, our relationship is with YOU and NOT your insurance carrier. We will file your claim with your insurance company as a courtesy to you. However, you are the sole responsible party for all charges incurred and must guarantee payment.

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  • CHANDLER FAMILY DENTISTRY POLICIES REGARDING FEES, SERVICES, AND INSURANCE

  • As your dental care provider, Chandler Family Dentistry strives to provide the best possible care using state-of-the-art techniques in a welcoming and safe environment. We do our utmost to provide accurate cost estimates for dental procedures. Please do not hesitate to ask questions or discuss your concerns with our knowledgeable and helpful administrative staff.

  • FEES AND SERVICES

  • Our fee schedule reflects a combination of usual and customary fees and local fee surveys. It also factors in time spent, the complexity of the procedure, supplies used, and lab fees. At a minimum, fees are evaluated on an annual basis. Chandler Family Dentistry does not send monthly statements.

    We expect payment in full for services when performed.

    I assume full responsibility for all charges incurred. I understand and acknowledge that if my dental account becomes delinquent, I will be responsible for payments of all unpaid balances, including but not limited to, finance charges, returned check charges, collection fees, court costs, and attorney fees.

  • Please acknowledge your acceptance by signing below.

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  • INSURANCE CLAIMS

  • There are almost as many insurance plans as hours in a year. Insurance reimbursement for dental procedures can be confusing. As a courtesy, we will file your insurance claims so you may receive all the benefits you are entitled to under your plan. However, it is prudent to be fully informed about the parameters of your coverage.

    Employers often provide insurance. Discuss your coverage with your employer or seek guidance from a plan representative. Many employers offer multiple plans; benefits can change yearly, as do co-pays and deductibles. Unfortunately, insurance companies often bundle or deny services that they feel are unnecessary or should be categorized differently. The contract between the insurance company and your employer or your insurance company and you determines fee reimbursement.

  • ASSIGNMENT OF BENEFITS

  • I authorize the release of any health information necessary for processing of insurance claims by Chandler Family Dentistry. I authorize payment of any insurance claims due to Chandler Family Dentistry to be paid directly to her. I authorize Chandler Family Dentistry’s staff to affix my signature on any dental insurance forms for myself and my family for the next five years beginning as of this date. A copy of this authorization will be valid as the original.

  • Please acknowledge your acceptance by signing below.

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  • APPOINTMENT CANCELLATION POLICY

  • Chandler Family Dentistry strives to provide excellent dental care to every patient, and scheduling adequate time with each patient contributes to that high level of care. However, when a scheduled appointment is missed without proper notice, it creates a lost opportunity for the practice to treat another patient.

  • THE CHANDLER FAMILY DENTISTRY APPOINTMENT CANCELLATION POLICY:

    We require that you give our office 48 hours’ notice if you need to reschedule your appointment. That allows for us to schedule another patient in your slot.

    A $75.00 “missed appointment” fee will be charged to your account if you do not contact our office 48 hours before your scheduled appointment. A “missed appointment” fee cannot be billed to your insurance company. Payment of this fee is your responsibility and must be received before future appointments are scheduled.

  • Reach out to our staff if you have any questions regarding this policy. They will be happy to address your concerns. Chandler Family Dentistry values every patient, and we appreciate the confidence you place in us as your dental care provider.

  • Please acknowledge by signing below that you have read and understood the Chandler Family Dentistry Appointment Cancellation Policy and agree to be bound by its terms. You also agree that the practice may amend such terms at any time.

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  • COMMUNICATION PREFERENCES CONSENT

  • With your consent, Chandler Family Dentistry will email and/or text you appointment reminders and dental care updates. Please note that text and email communications from Chandler Family Dentistry are NOT encrypted, and therefore, may be at risk, however minimally, of inappropriate access. We will never share your email address with third parties.

  • TEXT COMMUNICATIONS

  • EMAIL COMMUNICATIONS

  • Please acknowledge by signing below that you understand your communication instructions will remain in force until you update Chandler Family Dentistry in writing.

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  • HIPPA - AN ACKNOWLEDGEMENT OF RECIPT OF PRIVACY PRACTICES

    Complete ONLY if Chandler Family Dentistry is filing insurance on your behalf.
  • I am aware of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191HIPAA Privacy Practices set forth by the government and followed by Chandler Family Dentistry.

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  • FOR OFFICE USE ONLY

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