I hereby authorize payment directly to Lifetime Smiles of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize Lifetime Smiles to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge.

Thank you for choosing our office for your dental care. We are committed to the success of your oral health. We hope you and your family will feel welcome. We would like to acquaint you with our policies regarding dental insurance, financial arrangements, and schedule changes.

We don’t want finances to be an issue for our patients. We want you to be comfortable with us, and that includes your financial arrangements. We encourage you to enter into a financial arrangement that is comfortable for you.

• We accept cash, checks, Visa, Master Card, Discover, and American Express cards.
• For extensive treatments, we offer up to 12 months of NO INTEREST financing and long-term plans with low interest through Care Credit and Springstone. We will conveniently qualify you right here in the office today.

We will be happy to complete and forward all insurance forms regarding your dental treatment to your primary and secondary insurance company. Our professional treatment is rendered to you, not your Insurance Company. Please understand that the amount to be paid by your particular policy is pre‐determined and agreed to by your employer and the insurance company. If you have any questions about the amount the plan will pay or the treatments your plan will cover, you should refer these questions to your employer. At your request, we will provide all pertinent information to your Insurance Company, and we will do our best to help you derive the maximum benefits available; however, we are not responsible for determining what those benefits will be.

Please remember that dental insurance is designed to assist patients obtain dental care and rarely covers more than 1/3 to 1/2 of the total cost of the service. There may be a deductible, a coinsurance payment, and a yearly maximum. We will work with your insurance company to help you determine your benefits and copayments. Please keep in mind that all estimate fees that are quoted to you from your insurance company are not a guarantee of payment from them. We consider these fees as estimates only, and we are not implying that your portion of co‐payment is payment in full.

Late Payment Policy

If you have an outstanding bill that is not paid in full within 30 days after a bill has been sent, there will be a $20 Late Fee. There will be an additional $20 late fee for each bill sent out and not paid. If full payment is not received within 90 days, further collection efforts will be necessary.

Collection Accounts

If your account is sent to a collection agency, you will be responsible for any and all costs involved with the collections process, which includes all court costs and attorney fees.

Returned Checks: If a check is returned, a return check fee of $25.00 will be assessed.

Missed Appointments

Please understand that we take the time that we have scheduled for your appointment very seriously and we hope for the same consideration. Please consider your calendar carefully when scheduling an appointment. Missed appointments and appointment changes with less than 2 business days' notice will be charged a fee of $75 per scheduled appointment.

Your signature below indicates that you have read and agree to our Financial Policy and Dental Insurance Agreement. Thank you for being our valued patient.

I understand that, under the Health Insurance Portability Accountability Act of 1996, I have certain rights to privacy. In regards to my protected health information (PHI); I have received, read and understood The Notice of Privacy.

The practice reserves the right to change the terms of its Notice of Privacy Practice. I understand the Practice will provide current Notice of Privacy Practices on request.

If Patient is over the age of 18, or Patient would like us to discuss dental treatment, finances, etc. to anyone else such as a parent or spouse, please fill out the following information.

Name the person that we can discuss your care with