To 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.

Thank you for choosing Lansdowne Dental Associates as your dental care provider. We are committed to your successful treatment and outcome. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. 

All patients must complete our Information Form and provide insurance facts before seeing the doctor. 

Applicable payment is due at the time of service. We accept cash, checks, VISA/MASTERCARD and PayPal. 

Regarding Insurance

We will gladly submit your treatment to your insurance company. We cannot bill your insurance company unless you give us your insurance information. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. If your insurance company has not paid your account in full within 35 days, you are responsible to submit payment in full to our office within 10 days of notification. 

Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your dental insurance. 

All co-pays and deductibles are due prior to treatment. In the event that your insurance changes to a plan where we are not participating providers, refer to the above pararaph. 

Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. Your up front charges may include a 10% allowance for your insurance company's arbitrary adjustment of the fee schedule. 

Missed Appointments

Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $50 for each half hours of the scheduled appointment time. Please help us serve you better by keeping scheduled appointments. 

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. 

I have read this Financial Policy. I understand and agree to this Financial Policy. 

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Institute Portability & Accountability Act of 1996 (HIPPA). 

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
• Obtain payment from third-party payers for my health care services
• Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. 

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. 

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