asaydental.com - Patient Information

PATIENT INFORMATION
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RESPONSIBLE PARTY INFORMATION
Person responsible for account
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INSURANCE INFORMATION
PRIMARY INSURANCE
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Birth Date:

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SECONDARY INSURANCE
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I authorize Dr. Daniel W. Asay or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile, or paper form to my insurance carrier or any related entities that require such information to be submitted
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FINANCIAL POLICIES
Thank you for choosing Dr. Daniel W. Asay as your dental provider. We are committed to providing you with quality treatment and a positive dental experience. Please understand that payment is due at the time of service. Our office accepts cash, check, and debit/credit cards. Outside financing through Care Credit is also available upon request and approval.

INSURED PATIENTS
- Most dental insurance plans DO NOT cover 100% of treatment costs.Your portion of the bill, including deductibles and co-payments, is always required at the time of service.
- We will bill your insurance as a courtesy to you and will do our best to estimate portion as closely as possible. Your insurance plan is a contract between you and your insurance company. Any balance remaining after receiving payment from your insurance company becomes your responsibility.
- We will assist you in dealing with your insurance company, but ultimately, the responsibility lies with you. After 60 days the balance will be due in full.
FEES AND COLLECTIONS
- It is important that you keep your appointment! This is time that we have reserved just for you. Appointments that are cancelled within 24 hours of your scheduled time will be charged a $25 no-show fee.
- Returned checks are subject to a $20 return check fee.
- Any balance 60 days past due will be assessed a finance charge of 18% APR and a $3.00 re billing fee for each monthly statement that is mailed to you.
- Any balance 90 days past due will be turned over to a collections agency. A collection commission fee of the outstanding balance, plus any court costs and reasonable attorneys’ fees, with our without suit, incurred will be added to your past due balance and will also be your responsibility.
We thank you for the opportunity to serve your dental care needs and welcome any questions you may have concerning your care or our financial policies.

I HAVE READ, UNDERSTAND, AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I authorize payment of dental benefits, otherwise payable directly to me, to Dr. Daniel W. Asay, D.M.D. I understand that the responsibility for payment of dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand the finance, rebilling, collection charge, or attorney fees will be added to any overdue balance.
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I acknowledge that I have read a copy of this office’s HIPPA Privacy Policies. I agree to disclose to the dentist names of any individuals with whom I authorize the dentist to discuss my dental care.
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PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

FINANCIAL POLICIES