The information I provided is correct. I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

I understand the above information is necessary to provide dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask my health care provider for a release of information. I will notify the doctor of any change in my health or medication.

We are committed to providing you with excellent dental care. Your clear understanding of our Financial Arrangement and Appointment Agreement is very important to our professional dental relationship. When treatment is needed, we will make every effort to assist you in planning for the expense of the treatment. Prior to leaving our office, we will give you a written treatment planner with your treatment fees, estimated insurance coverage and estimated patient portions.

PATIENTS WITH INSURANCE – Your insurance policy is a contract between you and your insurance company. As a courtesy, we will assist in gathering and helping you understand your insurance information, and we will submit your insurance claim(s) on your behalf. INSURANCE IS NOT A GUARANTEE OF PAYMENT, IS SUBJECT TO CHANGE, AND OFTEN COVERS A PORTION OF FEES. Estimated patient portions and unmet deductible amounts are due at time of service and may be paid with cash, check, or credit card. After insurance claims are processed, any remaining balance is your responsibility. Irvington Dental is not responsible for incorrect information provided by your insurance company such as but not limited to omitted information, incorrect eligibility and termination dates, waiting periods, frequency limitations, maximum amount(s), deductible amount(s), downgraded or fall under the least expensive alternate treatment etc.

CARVE-OUT RULE – For patients with primary and secondary insurance, the secondary insurance may apply a carve-out rule when processing insurance claims. If the secondary insurance pays the same as or less than the primary insurance, the secondary insurance may pay ZERO.

PATIENTS WITHOUT INSURANCE – Full payment is due at time of service with cash, check if amount is no more than $150, or credit card.

SERVICE CHARGES – If the account balance is not paid within 30 days, a 1.5% service charge of the entire balance will be applied. If the account balance has still not been paid within 60 days, an additional 1.5% service charge of the entire balance will be applied.

COLLECTIONS – For patients with insurance, account balances not paid within 90 days of the final insurance payment will be sent to our collection agency and reported to all credit bureaus. For patients without insurance, account balances not paid within 90 days of the last date of service will be sent to our collection agency and reported to all credit bureaus. Patients reported to our collection agency are not welcome to reactivate.

RETURNED CHECK FEE - $25.00 will be added to your account balance if a check is returned from your bank as non-sufficient funds.

FINANCE OPTIONS – CARE CREDIT, GREEN SKY, LENDING CLUB – 6, 12, 18 months, no interest if paid in full within promotional period; 24, 36, 48, 60, 72, 84 months. Refer to the third-party finance brochure for more details.

DENTAL SAVINGS PLAN – Our savings plan helps adult patients pay for exams, prophylaxis (routine hygiene), periodontal maintenance, x-rays, and oral cancer screenings. A discount applies to dental treatment (doctor procedures). Refer to our Dental Savings Plan Agreement for more details.

TREATMENT DEPOSIT – A 50% NON-REFUNDABLE deposit of the total treatment scheduled for that day is required at the time you schedule your appointment. We will retain the deposit if the appointment is canceled or rescheduled within 48 hrs before the appointment.

FINAL PAYMENT – Any remaining patient portions and/or treatment fees must be paid at the final appointment.

TREATMENT PLAN FEES – Treatment fees will be honored for 12 months from the date the treatment was recommended. Treatment recommendations and fees are subject to change by the doctor.

FAILED APPOINTMENTS – A phone call will be made to patients who fail to arrive for their appointment. A $50 failed appointment fee will be applied to your account. We may refuse to reschedule.

LATE ARRIVALS – If a patient arrives late for an appointment, we will do our best to accommodate; however, if you arrive excessively late and treatment cannot be completed, we will apply a $50 late arrival fee to your account. You are allowed one reschedule per appointment after the fee is paid.

CANCELED OR RESCHEDULED APPOINTMENTS – We ask for more than 48 hour notice to cancel or reschedule an appointment. A $50 cancel/reschedule fee will be applied to your account for any appointments canceled or rescheduled within the 48 hours prior to the appointment. Habitual missed appointments are grounds for dismissal from the practice.

MINORS - All minor patients must be accompanied by an adult (parent or legal guardian). The adult accompanying the minor is required to pay in accordance with our policies.

I {patientsName} hereby grant permission for Irvington Dental to disclose my personal health information to the following personal representative(s): spouse, sibling, parent, child, friend, etc.

Right to Revoke: I have the right at any time to revoke this Acknowledgement for any reason.

I am a parent or legal guardian of {patientsName} (patient name). I have received a copy of Irvington Dental PC Notice of Privacy Practices effective 7/27/2015.