Do you now have, or have you ever had, any of the following conditions?
Please check ALL items that apply.
I understand I personally owe any amount, in whole or in part, for which the insurance carrier does not reimburse Atlanta Dental Center.
PATIENT ACKNOWLEDGMENT OF PRIVACY PRACTICES.
POLICY REGARDING DENTAL INSURANCE
Authorizations and Acknowledgements
By clicking the submit button below, I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
By clicking the submit button below, I authorize the diagnosis of my dental health by means of radiographs, study models, photophraphs, or other diagnostic aids deemed appropriate.
By clicking the submit button below, I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.
By clicking the submit button below, I authorize my payment details listed above to be charged for a non-refundable new patient reservation fee of fifty ($50.00) dollars. I further understand that this reservation fee only covers some or all of the following services as determined by the doctor. Services potentially covered are ADA Codes D0150, D0181, D0210, D0330, D0350, D0367. I further acknowledge that the reservation fee does not cover any other kind of dental work. The reservation fee cannot be paid by dental insurance and is not combinable with dental insurance.
By clicking the submit button below, I acknowledge that a doctor-patient relationship has not been established with any of the practitioners or staff or legal entities emlployed by or associated with the Atlanta Dental Center, LLC and Atlanta Dental Center, PC. (A doctor-patient relationship can become established when the patient has been seen by the doctor.)
By clicking the submit button below, I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
BEFORE CLICKING SUBMIT - After you click submit, wait for our website to load (atlantadentalcenter.com). Once our website has loaded, your information has been sent. Thank you!