Patient Registration

Dental Insurance Information

(Please give your insurance card to the receptionist)

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/herstaff will rely on this information for treating me safely and effectively. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I hereby grant permission to the doctor to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental care. I understand any photographs may be used for documentation and for educational purposes.

At our dental practice, the payment of your bill is part of your treatment, and we kindly request payment at the time services are provided. As your dedicated dental care provider, our relationship is with you, our patient, and not with your insurance company. As a courtesy to you, we will submit all insurance claims to your insurance provider and provide you with an estimate of the portion they will cover. However, please remember that you are responsible for all charges incurred, regardless of insurance coverage.

Once your insurance pays its portion, we will send you a statement for any remaining balance, which is due upon receipt. In case your insurance has not made payment within 60 days, the unpaid balance becomes your responsibility and may be subject to finance charges for the collection process.

If you should require assistance with financial arrangements, we require these arrangements to be made prior to your treatment appointment.

Credit Card Policy. Credit card payments will be allowed up to $1,000 with no additional fees. For any amount over $1,000, an additional 3% credit card processing fee will be applied to your account. To avoid the processing fee, we do accept checks or cash. 

Cancellation & Late Policy. Your appointment time is reserved for you. If you are running late for your appointment, please contact us to see if we can accommodate you or reschedule for a different day/ time. Minimum 48 hours advanced notice is required for cancellations, and notifications can be left on our answering machine after business hours. Missed appointments will incur a $125.00 charge per hour reserved for your treatment, and appointments exceeding two hours require a $250 reservation deposit. If you keep your scheduled appointment, this deposit may be credited towards your treatment.

Cancelled Checks and Past Due Balances. All returned checks are subject to $35 fee, and balances over 60 days will accrue interest at 18% annum. In the event of an unpaid account with past due balances, we may report it to all three major credit bureaus and assign it to a Collections Agency.

I have read and accept the terms of the above Financial Policy and Agreement and understand that I am fully responsible for payment of fees incurred regardless of any insurance. I have authorized Dr. Chen and Dr. Nagatomo to bill my dental insurance company and accept assignment of my dental benefits.

Privacy Policy

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
A copy of the Notice of Privacy Practices is available for your review at any time you request.