Please fill out the form in it's entirety.  Your privacy and safety is at the utmost importance to us. If you have any questions about this form, please do not hesitate to contact our office!

Insurance: To avoid any misunderstanding regarding dental insurance, it is our office policy to let our patients know that all professional services rendered are charged directly to the patient and that patients are responsible for payment of fees. We will prepare necessary forms and reports to help you obtain benefits from Insurance companies, upon receipt of full (or partial) payment of bill. We do not render our services on the basis that Insurance companies will pay all our fees. Each fee is individual for the individual patient. If you are covered by a Pre-paid dental plan, co-payment must be made when treatment is rendered.

Please CHECK any of the following that apply to you:

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my Doctor if I or my children ever have a change in health.

**I certify that I. and/or my dependent(s) have insurance coverage with And assign directly to Dr. Beckman all insurance benefits if any. Otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. *The above-name doctor may use my health care information man may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the dated signed below. **

The oral cavity is the window to the body. Many health problems that exist can present first in the mouth. In order to better serve our patients we ask you to provide a complete health history picture. Nothing is trivial. If you do not see something listed below, or is experiencing symptoms please list or describe them in the space provided at the bottom of the page.

Privacy Consent- For the use and Disclosure of Protected Health Information

This consent is required by Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.

I hereby give my consent to Dr. David R Beckman use and disclose my protected health information for the purpose of treatment, payment, and operations of my health care and the practice.

I, with my signature, authorize this family Practitioner and any employee working under the direction of this physician, to provide medical care for me, or to this patient for which I am legal guardian. This medical care may include assessment of my condition, management, treatment, and supportive care and services related to my needs and conditions. This may include (but not limited to ) evaluation of medical condition, medical management, procedures, diagnostic testing, therapeutic care, coordination of care with surgeon, hospital employees, and other medical specialists, home health care, counseling, the prescribing of drugs or other services required for you care. This may include photographs and other images to help with treatment planning at outcome assessment. This consent includes contact and discussion with other health care professionals, specialists, hospital personal, and therapists for your care and treatment.

Consent related to the Privacy Notice:

I have had a chance to review and Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change, and I may obtain these revised notices by contacting the practice by phone and writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on (PHI) use, it is bound by that agreement.

• I understand that this practice may refuse my services if I refuse to sign this consent. I may revoke this

consent at any time, but the practice may refuse further services at that time. If I revoke this consent, the revocation does not take effect until the practice receives it.

In an effort to reduce costs, increase efficiency and maintain a higher level of professional care, we have created a financial policy that both patients and office personnel must adhere to.

Our Office Policy is as follows:

1. We accept payments by CASH, CHECK, VISA, MASTERCARD, DISCOVER, AMEX and CARE CREDIT

2. As a courtesy, we will accept most insurance, and will gladly process your claim, however any estimated deductibles, and co-payments will be due in full at time of visit.

3. Although our office will process your insurance claims, please understand it is your responsibility to satisfy any account balance in full for all services rendered.

4. We require a 24-hour notice for all cancellations. A fee will be assessed if proper notice is not received at $ 80.00 per scheduled hour.

5. Additional costs may be applied to select treatments that need to be sent to an off site lab. A receipt of lab costs will be presented to the patient after the work has been completed. The patient will be responsible for this additional cost.

Our dental office sends appointment reminders, information about treatment, payment, and insurance information.  

By signing below, you are stating that you consent that the dental practice, may contact me to provide healthcare information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equiptment that may be capable of automatic dialing. 

As a courtesy to you, we will help you process all your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for a detail of your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.

All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract. 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.

In the past we have gone to extensive lengths to ensure to dispute errors with insurance companies to ensure our patients are able to fully take advantage of their dental plan. Sometimes, needing to resubmit claims numerous times.  However, throughout the pandemic, insurance companies have been reluctant to pay.

Insurance payments are ordinarily received within 30-90 days from the time of filing a claim. If your insurance company has not made payment within 90 days, we will ask that you contact your insurance company to make sure payment is expected.  We will happily provide you with any additional x-rays or documentation you may need.  However, if payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.

By signing this updated policy, I understand the I am responsible for all charges incurred.  I understand that any treatment not covered or denied by my insurance company is my financial responsibility.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This is a formal notification, as required by the government concerning the privacy policy of this practice. This practice has an obligation to maintain all medical information in the strictest of confidence. Our practice cannot release information without your written consent, including medical records, conversations, reminder calls, test results and other confidential issues. Patient information about health care is identified as “PHI” or protected health information. You can change this information at any time with either written notification or verbal notification, followed up in writing. Changes can only impact the care or information for that point in time.

o Your protected health information (PHI) is part of your medical care, and can be used or disclosed as follows: o For your treatment in this practice and other locations under our immediate care for care needs. This may include any medical assessment, diagnostic testing, treatment and procedures related to your needs. This may include coordination with others (Surgeon, Radiology, and Specialists) for your care, referral for services, diagnostic tests or treatment related to your medical care needs. This may also include discussions with home care agencies, Hospice, spiritual support, counselors, and others should you need these services during the course of your care. o For obtaining payment for treatment with your identified health care program. This would include any documentation related to this care, including history forms, progress notes, pictures and/or video tape and procedure notes. This would include eligibility verification, prior authorization and claim submission. o For operations of this practice, such as enrolling with insurance programs. Hospital privileges, Quality Care Programs and compliance with federal and state laws and regulations: o Appointment reminders and health related benefit services only with your consent identified on the registration form. o Disclosure to your family and friends concerning any related health care information given on the registration form, which can be modified at any time orally, followed by written consent. o Consent is not required for emergency care and treatment. An emergency is identified as a medical condition that in the judgment of the physician requires information for care on your behalf.

Certain disclosures can be made without your consent, and they are as follows:

o    Disclosure required by the government or law enforcement agencies. An example would be victims of abuse.

o    Information used for public health purpose, medical examiners and related to a person’s death or for the health department for disease tracking. This would include information to a funeral director after death concerning any artificial devices you may have in your body. Information is only released to executors of estates in most cases.

o    Information used for health care oversight, such as a site reviewed by an insurance program.

o The right to request limits on the use and disclosure at registration or any time during you care.

o The right to choose how we sent this information to you, including an alternate address.

o The right to see and obtain copies of you PHI, but there may be copy and postage fees. o The right to get a listing of who we have made disclosures to about your PHI. The right to correct your file through an amendment process if appropriate. o This practice reserves the right to modify or change the privacy statement and process at any time. Revision to the notice will be available upon request by contacting the office. The changes will be effective retroactively to the initial date of the privacy notice. o An updated privacy notice will be posted in the office within 60 days of the revision.

If you have a concern or complaint about how your protected health information is being used, you should first contact your Practice Administrator in your Business Office to resolve your concerns, or you may contact the Office of Civil Rights or the Ohio Medicare Carrier GBA Palmetto.

Office of Civil Rights- Regional Manager Palmetto GPA Dept. of Health & Human Services Part B Operations- HIPPA Compliance Concerns 233 N. Michigan Avenue, Suite 240 P.O. Box 18957 Chicago, Illinois 60601 Columbus, Ohio 43218

Our office does accept CASH, CHECKS, MONEY ORDERS, VISA, MASTERCARD and DISCOVER. ALL FEES, co-payments are due day of service. Fees for major work such as crowns, bridges, dentures and implants need to be satisfied before the placement appointment. If you cannot do so, arrangements need to be made in advance at the front desk. Our office does offer payment plans for certain procedures. Our policy is at least 50% down and remaining 50% in equal payments over the next three to six months. A payment plan will be set up according to your Treatment Plan. Payment booklets can be provided. We will not change interest during agreed payment plan time period; however, any balance remaining will incur an interest rate of 18% APR (Annual percentage rate.)

After examination, or consultation, you will receive a written plan for your dental treatment. This treatment plan will inform you of all the treatment and options discussed with your clinicians and gives you a specific breakdown of costs and insurance benefits if any. Emergency appointments will receive limited treatment plans and must not be construed as a comprehensive treatment plan.

Our office will gladly file an appropriate insurance document for any procedure we perform. Unfortunately, the insurance companies have an adversarial relationship with dentists. The insurance companies are in the business to make money and sometimes this will be reflected by their reluctance to process a properly completed claim. We will re-submit an insurance claim up to three separate times in order to fulfill the insurance companies’ needs. However, after three attempts we must ask our patients or someone from their employer’s personnel department to call to expedite the processing of their claim. Also, at that time you will be responsible to make arrangements to pay the balance. We will continue to work on your behalf to obtain benefits and resolution of that benefit will be paid back to you. Remember, the relationship is between you and the insurance company, and they can decline to work with us. Any balance remaining is still the patient’s responsibility.

Certain patients without dental insurance can benefit from Dr. Beckman’s Plan. For a nominal yearly fee, individuals and families can receive free checkups and save 30-50 % on most dental procedures. Inquire with the front desk on whether Dr. Beckman’s Plan would benefit you.

Our office recognizes that your time is valuable. We make every effort to see you at your scheduled appointment time. Emergencies occur and if we are behind, we will notify you so that your schedule is not adversely affected. While we are still accepting new patents, our “chair-time” is at a premium. If you cannot make a scheduled appointment, we ask that you give a 48hr. notice for non emergency situation. Often with proper notice we can give your time to a patient that needs to be seen for emergency care. Cancellations without notice will be subject to an $80.00 per scheduled hour fee.

BY SIGNING BELOW I ACKNOWLEDGE I HAVE RECEIVED THE NOTIC OF PRIVACY STATEMENT AND HAVE COMPLETED ALL SECTIONS OF THIS FORM TO THE BEST OF MY KNOWLEDGE.