• Adult Assessment Form

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  • Have you experienced any of the following issues?

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  • FINANCIAL POLICIES

    Arrangement and Conditions
  • Welcome to East Bay Tongue Tie Center. We are pleased that you have selected our office for you or your child’s care and we value the confidence you have expressed in choosing us. We understand that parents are concerned not only with the quality of their children’s care, but also with the costs of professional services. Therefore, we have outlined below the financial policies of this office.


    • Payment is expected the day service is rendered. This includes co-payments and deductibles.


    • If you carry dental insurance, we will provide you with a superbill for you to submit to your insurance for reimbursement.


    • We will also provide you with the medical diagnostic and treatment codes so you can submit your superbill to your medical insurance as well if you would like.


    • We appreciate if you are not going to show up to your appointment, please let us know as there are other families wanting appointments and slots are limited.  If you no show or cancel within 48 hours, you will need to make a deposit of $100 if you would like to reschedule which will go towards your consult fee of $250.


    • Please remember, once an appointment has been made this time as been reserved especially for you or your child.


    • Please make sure that the new patient paperwork is filled out and submitted 48 hours prior to the appointment as this will be a confirmation of your appointment.


    • There will be $25.00 fee for returned checks due to insufficient funds.
     

  • I understand that I am responsible for all fees associated with my appointment.  A superbill will be provided to me if I would like to submit to my insurance.  


    The parent/guardian, signed below agrees to be fully responsible for the total payments of procedures performed in this office. In cases of shared custody and/or divorced/separated parents, the parent/guardian presenting the child for treatment is responsible for the charges incurred.


    I have read and fully understand the financial policy of this office and have received a copy.

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  • MEDICAL INFORMATION RELEASE FORM

    (HIPAA Release Form)
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