To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. 

Our office is committed to providing you with the best possible care. If you have dental insurance, we will help you to receive your maximum allowable benefits. To do this, we need your assistance and your understanding of our financial policy.

Payment for services is due at the time services are rendered. We accept cash and all major credit cards. We also offer no-interest payment plans for 6 or twelve months through CareCredit and CHERRY. If you have insurance, we will be happy to process your claim for you. Please be prepared to pay your estimated portion on the date of service. It is impossible for us to know all our patients’ insurance coverage and additional payments may be necessary once your claim has been processed.

Late/NO- Show Policy: To ensure we can accommodate all our patients; any cancellation or rescheduling requests must be submitted 24 hours in advance. A fee of $40.00 will be imposed for the second consecutive no-show. The patient will be dismissed from the practice after three consecutive no-shows. If you are 15 minutes late on arrival, your appointment will be cancelled, and you will be asked to reschedule.

Returned checks will be subject to additional collection of $25.00

Our office will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize however that your insurance is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Dental insurance is not meant to be a pay-all: It’s only meant to be an aid. Many routine dental services are not covered by dental insurance at all. If you should have any questions regarding your coverage, YOU should contact your company.

We must emphasize that as dental care providers, our relationship is with you, NOT your insurance company. While the filing of all insurance claims is a courtesy we extend to our patients, ALL charges are YOUR responsibility.

In a single parent family or divorced situations where children are involved, the parent bringing the child/children to the office for treatment will be fully responsible for payment.

If you have any questions about the above information or are uncertain regarding insurance information, please do not hesitate to ask us. We are here to help you.

ASSIGNMENT & RELEASE: I have read all the information on this sheet. I hereby authorize my insurance benefits to be paid directly to Lenderman and Meek Dental. I understand and agree that (regardless of my insurance), I am responsible for the balance on my account for any professional services rendered. In the event that the services of an attorney or collection agency is required to collect any portion of payment due for my dental services rendered, additional fees may be incurred. I understand and agree that I will be responsible for payment of ALL fees related to collection of my account including attorney fees, collection agency fees and court costs.

THIS NOTICE DESCRIBES TO WHOM MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides privacy protections to your medical records. Our benefits office (or other third party designated by our office) may sometimes need to disclose medical information or payment information protected by HIPAA in relation to our group health plans to your family members or close friends involved in your health care. For example, your spouse may need to contact us if you are in the hospital to determine whether a particular procedure is covered under our group health plan or may need assistance filing a claim for medical services. Under HIPAA, unless you specifically object we are allowed to use our professional judgment in deciding whether to discuss you medical and payment information with you family members or close friends. However, we would like to provide you with the opportunity to tell us with whom we may discuss your medical or payment information under our group health plans.

COMPLAINTS

If you think that we have not properly respected the privacy of your health
information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office
contact person at the address or phone number shown at the beginning of this Notice.