Thank you for taking the time to fill out this form accurately and thoughtfully.

There are three pages, and it should take 5-10 minutes to complete.

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize my dentist to contact my physician, listed below.

Insurance & Coinsurance: If you have insurance coverage, we will make our best efforts to coordinate your care in a cost-effective manner within the limits of your insurance benefit and to minimize the expenses for which you are responsible for. Your policy determines the extent to which you will be responsible for all deductibles, copayments, co-insurance, and non-covered services. Forever Dental is not responsible for incorrect information given by your insurance company or failure of your employer to provide accurate information to your insurer about your employment status. The coverage available to you depends upon your employment status and the choices you make within the plans that are offered to you buy your employer. We rely on you to keep Forever Dental up to date with correct information about your coverage. This information includes, but is not limited to:

• Change of your employment status or status as a beneficiary under family coverage
• Change of insurance company or plan offered by your employer
• Loss of insurance coverage or bankruptcy of your employer

Insurance Copayments & Deductibles: You are financially responsible for all charges incurred for treatment unless we can verify insurance benefits and expect to receive payment from a valid insurance plan. Patients that have dual dental coverage will still be responsible for any non-covered services by either primary or secondary insurance. Each insurance may have its own deductible and must be met individually by the patient.

Fees, Scheduling, and Collection: Forever Dental may find it necessary to decline to treat any patient if the insurer or patient has not made payment. There is a charge of $25 for Not-Sufficient-Fund checks along with the amount for the check. We make every effort through text messages, email and voice message to confirm and remind you of your appointment. We reserve the right to charge $35 for cancellations of less than 48 hours, multiple reschedules and no shows. Excessive abuse of re-scheduled and/or canceling appointments may result in discharge from the practice. All costs incurred for the collection of past due accounts, including reasonable attorney’s fees will be passed onto you.

Minors: Minors must be accompanied by a parent or a guardian to be seen in the office, unless special arrangements have been made with the office.

Notice of Privacy Practices/HIPAA. The Health Insurance Portability and Accountability Act of 1996 requires that health care providers give patients a copy of the office Notice of Privacy Practices and make a good faith effort to obtain an acknowledgement of receipt of same. You may refuse to sign this acknowledgement form. Please be advised that we do communicate with our patients by text messages, voice mail, e-mail and postcards. Please let us know if you would like to place any restrictions on this.

The Notice of Privacy Practices can be downloaded here.

I hereby authorize payment directly to Forever Dental of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize Forever Dental to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information in this form are correct to the best of my knowledge. I grant the right to the dentist to release my medical/dental histories and other information about my dental treatment to third party payers and/or other health professionals.