Online Patient Form

Patient Name *

First Name Middle Name Last Name

Insurance

We are pleased that you have insurance benefits to help with the cost of your orofacial care. We would like to help you obtain the maximum use of these benefits. With this in mind, please read the information on our insurance claims process so that we can work together to maximize this benefit.

DO YOU ACCEPT MY INSURANCE? HOW MUCH WILL THEY PAY?
We will provide you a walkout statement called a “superbill” that itemizes your treatment for insurance reimbursement. When YOU submit this superbill, the insurance company should reimburse you directly. Please check with your insurance company prior to your appointment to see if you will be reimbursed.

INSURANCE DIDN’T PAY, NOW WHAT?
We provide you with a “superbill” as a courtesy. It is YOUR responsibility to collect the insurance funds that are due to you. The insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be, a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

FINANCIAL OPTIONS
Payment for treatment rendered is due at the time of service. We accept MasterCard, VISA and CareCredit. If you are in need of an extended finance option, your local credit union may offer payment options. These are all designed to meet your treatment plan needs.

We welcome you and look forward to helping you achieve your wellness goals. If there is anything we can do to make your visits here more pleasant, please don’t hesitate to ask one of our staff members.

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I understand that 50% of NPX cost is due at time of booking.

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I have read, understand, and accept the terms of the above outlined policies for insurance handling and financial commitments that I may incur as a result of treatment at Sacramento Natural Dentistry.

Financial Policy

We appreciate the trust you have placed in us by choosing our dental practice. In order to make your experience smooth and pleasant, we ask that you read and acknowledge our financial policy.

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Payment is due at the time of service. Cash and cashier checks are accepted. A fee will be charged for returned checks. If an extended payment plan is desired, please ask your credit union. MasterCard and VISA credit card payments are also welcome. If you have any questions, please feel free to ask.

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I understand and agree that all services rendered me, my dependents, or others assigned by me to my account are charged directly to me. I further understand I am personally responsible for payment. If I suspend or terminate care and treatment, any fees for services rendered will be immediately due and payable.

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I understand that if I make an appointment, I am responsible for keeping that appointment. We require minimum 50% down for all scheduled treatment appointments. If payment is paid in full at appointment scheduling a 3% discount for cash/check payment will be offered. Credit card payments do not qualify for 3% discount. If full payment isn't received prior to treatment date, the 3% discount will not be available for day of treatment payment in full. In the event that I cannot make an appointment, I understand that I must provide at least 48 business hours notice and $100 will be charged per each scheduled hour. If an appointment of 2 hours or greater is necessary, I agree to pay $200 to reserve the appointment. I understand the $200 will be applied toward the cost of treatment provided during the appointment.

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We suggest and encourage you to discuss office visit and procedural costs at the time of service to avoid misunderstandings. Failure to do so does not absolve you of responsibility for charges incurred.

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I understand that there is a charge for all dental, pain, and sleep apnea consultations with Dr. Azouz.

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I agree to be responsible for payment of all services rendered on my, or my dependent's behalf. I understand that payment is due at the time of services unless other arrangements have been made beforehand.

If you have insurance…
As a courtesy, we will provide you a “superbill” at the conclusion of your treatment. You may submit this form directly to your insurance provider. Any payments from the insurance company will be sent directly to you. Dr. Azouz is not a preferred provider for ANY insurance company. You may find that our fees may be different from the insurance company's schedule of "allowable" or "UCR" fees. If you have questions about "UCR" fees, please feel free to ask. All services rendered are charged directly to the patient, and the patient is ultimately responsible for the account regardless of insurance coverage. If a claim is denied, or if the insurance does not pay what you thought they would pay, it is YOUR responsibility to file an appeal.

In the event that my account is not paid as agreed, and must be turned over to a collection agency for settlement:

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I agree to pay a collection fee, charge, or commission equal to the amount of 50% or the account balance, in addition to the outstanding account balance. I also agree to pay attorney fees and court costs associated with the collection of any outstanding balance.

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I understand that a 1.5% monthly finance charge (18% APR) plus the costs of any necessary collection fees may be added to my account.

Signature *

Clear

Date *

Date

(Your digital signature (full name) is as legally binding as a physical signature.)