Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Are you now taking:

Are you allergic to, or had a reaction to:

1-4 below for women only:

(Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.)

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above, have been answered to my
satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

This signature on files is my authorization for the release of information to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Dr. Alter and the team at Beautiful Smiles of Bayonne are committed to providing you with the highest quality of care, as your health and well-being are our primary concern. Please understand that prompt payment of expenses is part of the treatment process. To assure a mutual understanding of our fee structure and payment requirements, we ask each patient to read and sign this brief explanation before beginning treatment.

Payment for services is due at the time treatment is rendered. We accept cash,

checks, Visa, MasterCard, Discover, or American Express cards. If you are in need of a

financial option, we also work with Care Credit, who offers short term and extended-term

financing options designed to meet your treatment plan needs on approved credit. Just ask us for an application or apply online at www.carecredit.com.

We must emphasize that as a dental care provider, our relationship is with you, the patient,

not your insurance company. While the filing of insurance claims is a courtesy that we

extend to our patients, all charges are ultimately your responsibility from the date of service

rendered. We currently accept several insurance plans and estimate your portion based on

the most up-to-date information we have, but it is ONLY AN ESTIMATE. Most dental benefit

plans are meant to assist with dental costs but will rarely pay for your complete dental care.

If you have any questions regarding your dental benefits, please contact your employer or

insurance company directly.

 

If insurance does not pay within 60 days, we reserve the right to request payment in full for

services from you and let you collect the insurance funds that are due to you. This is rare but

it is important that you recognize that the insurance you have is a legal contract between

YOU and your insurance company. Ultimately, you are responsible for all charges incurred in

our office.