I have reviews the information on this questionaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the doctor to help determine appropriate and healthful dental treatment. If there is any chance in my medical status, I will inform the doctor.
I authorize the insurance company indicated on this form to pay to the doctor all benefits otherwise payable to me for services rendered. I authorize the use if this signature on all insurance submissions.
I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsiible for all charges whether or not pain by insurance.
Payment is due in full at time of treatmen, unless prior arrangments have been approved.
Please read this document carefully as it sets forth your financial responsibility for the services you receive in this office.
As with any healthcare profession, the patient receiving the service or the patient's legal guardian is responsible for all charges incurred. We accept cash, personal checks, MasterCard, VISA, Discover and Care Credit. Additionally, we gladly accept payment for your services from a family member with that person's approval. All payments, including credit and debit card payments, for initial, ongoing and completed services are non-refundable. We are happy to discuss special payment arrangements, in the event extensive dental treatment is needed, such as outside financing with third party companies.
CREDIT CARD We accept Visa, MasterCard, Discover and American Express. The cardholder’s name, card number, expiration date, security code, and card type must be included with the credit card payment. Fee Notice: All of our current fees are the rates for cash and check (paper or electronic). For payments made with your credit card and debit card, a 3.95% processing fee will be added to your receipt. ACH TRANSFER We accept ACH payment (electronic check) directly through your bank account. To process an ACH payment over the phone, we will need your bank routing number and account number.
We are happy to discuss special payment arrangements, in the event extensive dental treatment is needed, such as outside financing with third party companies.
As a courtesy, if you have a dental insurance plan, this office will file dental claims on your behalf with all necessary information. In that event, we may agree to defer a portion of the total charges for a period of up to 60 days with a valid assignment of dental benefits (for amounts that may be payable by insurance). Even if we agree to defer a portion of the total charges for up to 60 days pending payment of your dental claim, the estimated deductible, co-payment portions and amounts exceeding your dental plan benefit period maximum must be paid by you or your legal guardian on or before the date that dental services begin. Our office is certified and credentialed to bill your medical insurance plan to further offset your costs.
You agree to receiving emails regarding announcements and educational services from our office, and you agree to our use of photographs and videos taken from your procedures for educational purposes.
Generally, at your first appointment, evaluation/consultation and X-rays are provided, sometimes on an emergency basis. The fees for these services are due and payable when the services are provided, unless we have agreed to defer a portion of the total charges for up to 60 days with a valid assignment of dental benefits. If, as a courtesy, we have agreed to bill your dental insurance plan, you should be aware that most plans have annual limitations on these types of services, so the fees for these services may become part of your out of pocket expense. The fee for the specialist evaluation only (not including X-rays or other services that may be rendered at the time of evaluation) is $250.00.
Should you decide to discontinue treatment in this office after dental treatment has been initiated, you will be charged for all services rendered to date. Payments you have made for treatment that you have chosen to discontinue are non-refundable. Full payment is due for all completed treatment, regardless of the prognosis or outcome, short term or long term, for any service performed.
This office charges 100.00 for appointments canceled without 48 hours advance notice. For payments made by check, please be aware that any check returned to our office by the bank for any reason will incur an additional service fee of $35.00.
Outstanding charges are expected to be paid in full within 30 days of the invoice date. Finance charges of 1.5% monthly will be incurred on all outstanding balances beginning 30 days from the invoice date. If full payment is not received within 30 days of the invoice date, you will also be subject to a late payment fee of $30.00. In the event that your account becomes delinquent (any account that remains unpaid for more than 30 days will be deemed delinquent), you agree to be responsible to pay all costs of collection. This includes, but is not limited to, a $30.00 fee, all fees assessed by a Debt Collection Service (if we contract such services), and all arbitration costs and attorney's fees. You should be aware that a collection action on a delinquent account includes the reporting of your debt to the national credit bureaus, which may adversely affect your credit standing.
In addition, in consideration of the dental services provided by our office, you hereby agree that any and all disputes, including but not limited to clinical or financial related disputes between you and the office shall be submitted to binding arbitration in San Mateo County, California in accordance with the most recent version of the Commercial Arbitration Rules and Mediation Procedures of the American Arbitration Association, which can be found at www.adr.com. You and the office will share the cost of the arbitration, including the arbitrator’s fees. The arbitrator’s decision and ruling must be pursuant to California and applicable federal law and the California Evidence Code. The parties to the arbitration shall be entitled to all discovery established in the California Code of Civil Procedure at the time in which the matter is submitted to arbitration. The arbitrator shall have all powers to render the decision as any judge in a court in the State of California. Notwithstanding any rules or procedures of the American Arbitration Association to the contrary, the arbitrator shall be bound to render a decision in accordance with applicable state and federal laws and shall issue a written opinion setting forth findings of fact and conclusions of law which shall be final and binding upon each party. Any arbitration award shall include an award of reasonable attorneys’ fees and costs to the prevailing party as determined by the arbitrator. If any provision of this arbitration agreement is held to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force without being impaired or invalidated in any way and any provision held to be too restrictive shall be modified to give effect to the intent of that provision.
A signed copy of this financial policy and payment agreement will become part of your permanent patient record.
I have read and agree to the terms outlined in this financial policy.
I hereby give my consent for Dr. Angela Leung, D.D.S.,P.C./The Endodontic Implant Center to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Angela Leung, D.D.S.,P.C./The Endodontic Implant Center describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Angela Leung, D.D.S.,P.C./The Endodontic Implant Center reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Angela Leung, D.D.S.,P.C./The Endodontic Implant Center 1131 Mission Road South San Francisco, California 94080
With this consent, Angela Leung, D.D.S., P.C./The Endodontic Implant Center may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Angela Leung, D.D.S., P.C./The Endodontic Implant Center may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Angela Leung, D.D.S., P.C./The Endodontic Implant Center may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Angela Leung, D.D.S., P.C./The Endodontic Implant Center restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Angela Leung, D.D.S., P.C./The Endodontic Implant Center to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Angela Leung, D.D.S., P.C./The Endodontic Implant Center may decline to provide treatment to me.
If yes, what is the result of the testing?
If negative, proceed to next question.
If still waiting on results, schedule appointments after results are known.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.