Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.
***You May Refuse to Sign this Acknowledgement**
I acknowledge that I have received a copy of the office’s Notice of Privacy Practices. (We can make a copy at your request)
Authorization to release information
Purpose: This form is used to obtain authorization to release your information covered under the Privacy Act to people other than yourself. I Name Authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.
Procedures and Policies
PLEASE READ THESE PAGES CAREFULLY THEN SIGN:
By signing this form, I do hereby give permission for all dental treatment by or under the supervision of the dentist above.
I consent to the release of patient information to my insurance company for processing of my claims.
I also consent for the release of my information for outside referral specialists.
I authorize the use of email and/or electronic messaging to contact me in relation to my dental care.
I agree to pay fees in the usually and customary manner, and I understand that fees for an office visit must be paid at the time of the visit unless an agreement has been made with the collection department prior to the visit. I also understand that I, AND NOT MY INSRUANCE COMPANY, AM RESPONSIBLE FOR ANY DENTAL FEES.
I agree and understand that any fees that are not paid at the time of the visit, or at the time agreed upon between the collection department and me, if applicable, will bear interest at the rate of 5% per annum. I also understand and agree that if I do not pay these fees as I have agreed, I will be responsible and obligated to reimburse this dental practice for all costs and expenses (including, without limitation, attorney’s fees and charges) reasonably incurred by this dental practice in enforcing or collecting, or attempting to enforce or collect the fees.
NON-COVERED ROUTINE SERVICE POLICY:
We file your insurance as a courtesy. Dental insurance is a contract between the employer and the patient. It has no connection at all to us as your dental office. The extent of coverage varies greatly from company to company, sometimes even within a company. It has absolutely nothing to do with the level of service provided by us, and the fee charged for these services. We want to provide you with the best dental care possible. There may be routine services and cost that may not be covered by your dental contract. You will be responsible for any remaining balance that your insurance does not pay in full. We estimate your portion based on the most up to date information we have, but it is only an estimate. It is IMPOSSIBLE to give you a guaranteed quote at the time of service. However, we will make every effort to be as accurate as possible.
TERMINATION OF TREATMENT:
By signing this form, I hereby understand and agree that the dentists in this practice may terminate the dentist-patient relationship. We base our relationship on mutual respect between the dentist and the patient, and any event or action by the patient, which disturbs this trust, including significant failure to comply with our treatment recommendations, failure to take responsibility for payment of fees, knowingly falsifying information or other actions not mentioned here will result in a termination of our relationship.
NOTE FOR BLUE CROSS PREFERRED PATIENTS:
When receiving a posterior composite restoration, you are responsible for paying the difference between the Blue Cross allowance for the amalgam and the PDP fee schedule for the posterior complete.
POLICY CONCERNING DIVORCE SETTLEMENTS:
The policy of this dental practice is that the person signing as the responsible party for the child of divorced parents must arrange for the payment to be made at the time of the child’s office visit. Regardless of the terms of your divorce settlement, whoever brings the child in must pay for the office visit at that time.
Late and Missed Appointment Policy
At Hartselle Family Dentistry, we put our faith in you to keep your appointment. When we set up an appointment, a certain amount of time is reserved specifically for you. Many offices double or even triple book their schedule to prevent from being financially damaged as a result of a missed appointment. However, double booking appointments does not allow us to give the care and attention needed to provide excellent quality dentistry and for this reason we choose not to do it. When a patient cancels too close to their scheduled time, we are unable to fill this appointment time with another patient who is also needing dental care.
Our policy is as follows: We require that you give our office 24-hour notice in the event that you need to cancel or reschedule your appointment. This allows for other patients to be scheduled into that appointment.
For all hygiene/preventative appointments after a 2nd missed appointment, the patient will be placed on a short notice list and will be notified when there are openings on the schedule. No hygiene appointments will be scheduled ahead of time until the patient’s account is placed back in good standing.
Late Arrivals: When we reserve time for you, we require ALL of that time to provide you with the best quality dentistry as possible. When you are later that inhibits our ability to accomplish this. If you arrive more than 15 minutes late, your appointment will be rescheduled in order to meet the needs of those who are on time for their pre-reserved visit. If this happens it will be considered a missed appointment and the fees will still apply.
We understand that true emergencies happen. If this is the case, please provide us with a doctor’s note or other adequate proof and the missed appointment will be removed from your accounts record.
I have read the policy above and I understand and agree to the listed terms. I also understand and agree that such terms may be amended from time-to-time by the practice. I acknowledge that I have received a copy of Hartselle Family Dentistry’s Cancellation/Missed Appointment Policy and Treatment Policy. We welcome you to our family and look forward to helping you obtain and maintain the healthy, beautiful smile you deserve. If there is anything, we can do to better serve you, please do not hesitate to ask any of our staff.
This is to inform you of our new Appointment Confirmation Policy at Hartselle Family Dentistry. This new policy will allow us to better serve our patients by ensuring that your reserved appointment is confirmed and to better accommodate patients who are seeking an appointment.
Here are the key highlights:
We have every opportunity for our patients to confirm and commit to their dental appointments. Two business days prior to the appointment, all unconfirmed appointments will be made open and available, so we may better serve our patients that are waiting to see their Dentist and/or Hygienist. Our goal is to provide the high-standards in dental care and to continue to take care of all our patients’ dental needs. We appreciate your understanding and prompt confirmation of any appointment times you reserve. Thank you!
We will begin collecting a deposit to hold any appointments scheduled with the doctor for treatment.
1-Hour appointments $75 deposit
More than 1-Hour $125 Deposit
This must be paid ahead of being placed on the doctor’s schedule to reserve your time. This deposit will go towards your co-pay for the appointment.
IF FOR ANY REASON YOU HAVE TO CHANGE OR CANCEL THE APPOINTMENT, we require 24-Hour notice as stated in our Late Cancel Policy that you sign in the patient paperwork.
IF YOU DO NOT PROVIDE 24-HOUR NOTICE FOR APPOINTMENT CHANGES,
THIS DEPOSIT IS NON-REFUNDABLE AND WILL APPLY TOWARDS YOUR LATE CANCELLATION FEE.
*Exceptions to this are subject to review by the doctor and office manager*