We gladly process your insurance claims on your behalf. Please note that your insurance policy is a contract between you and your insurance carrier.
In the event of an emergency, Please provide a contact:
To the best of my knowledge, the questions on this form have been accuratley answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any charges in medical status.
Please select the letter of the response that is closest to yours:
Thank you for filling out these forms completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.
We want our office to have a friendly and personable atmosphere. We will work together as a team to offer our patients the latest techniques in dentistry. Our office constantly takes continuing education courses which enable us to perform dentistry which exceeds the standard of care today.
We have committed ourselves to the total well being of our patients. We will be compassionate and understanding of their dental concerns. We value each and every person in our practice. We strive for constant improvement and excellence. We strive to develop confidence and a feeling of accomplishment with our patients..
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
We are very appreciative of patients who arrive on time for their scheduled appointments. In the unlikely event you need to cancel an appointment, we request notice at least 24 hours in advance of the appointment. As a courtesy, our office may contact you to remind you of the appointment(s). While certain emergencies and other issues may be taken into consideration, Dental Masters of Belmont reserves the right to apply a fee to your account for failure to provide adequate notice. Guarantee of
Payment/Assignment of Insurance Allowances:
Unless otherwise stated, I understand that fees are due for any services rendered on the date of service. I authorize payment for services rendered to me to be made directly to this office for allowances otherwise payable to me. These payments shall not exceed the regular charges for this period of treatment. I also understand that I am responsible to pay any charges not covered through my insurance allowances, including but not limited to non-covered services, applicable deductible and/or co-insurances as defined by my policy(ies), or any fees for services in the event that I do not have insurance coverage. Completion of
In the event that I elect to receive treatments such as crowns, dentures, root canals, bridges, implants, and other treatment that requires me to return for future visits to finalize, I understand that I am responsible to return to the office to complete treatment. These types of treatments typically require Dental Masters of Belmont to incur lab, equipment, and labor costs up front. In the event that I do not return to complete the treatment, I understand that I am still responsible to pay the full cost of the treatment.
Past Due Balances & Collection Services:
Dental Masters of Belmont makes an effort to provide all patients with education and information regarding proposed and completed treatment, as well as the costs associated, in order for each patient to make an informed decision regarding their treatment. I understand that should my past due balance be referred to an attorney or collection agency, I will be financially responsible for any additional costs incurred such as attorney fees, collection agency fees, court costs, etc. I agree to abide by the protocols listed above. I understand that if I have any questions about these protocols, I may request assistance and further explanation at any time from a Dental Masters of Belmont team member.