benyountdds.com - Office Policies

Patient Name:*

Date of birth:*

Date

Address:*

Cell Phone:

Please enter a valid phone number.

Home phone:

Please enter a valid phone number.

Email address:

example@example.com

Preference for appointment reminders:

Phone callTextEmail

Changes in your dental insurance? Please let us know

HIPPA Notice of Privacy Practices (See laminated sheets on clipboard. Copies available upon request.)

I have received and have been given the opportunity to review the Notice of Privacy Practices.

Initial:*

Dental Materials Fact Sheet (See laminated sheets on clipboard. Copies available upon request.)

I have received a copy of the Dental Materials Facts Sheet.

Initial:*

Appointment Cancellations Policy

Your appointment time is reserved specifically for you. Other than in an emergency, if you are unable to keep your appointment, please give us 48 business hours notice (we are closed on Fridays). You get plenty of texts, calls and/or emails up to one month before your appointment to allow plenty of time to reschedule. If advance notice is not received, a charge may apply.

Initial:*

Insurance/Payment Policy

You are ultimately responsible for the entire cost of your treatment regardless of your insurance coverage. Our office will process insurance claims as a courtesy to you, based on insurance information provided by you. You are ultimately responsible for knowing your own insurance coverage and limitations. We do everything we can to have an accurate estimate of the patient portion for your treatment. Please note that any estimates given are estimates only and are not guarantee of payment as some restrictions set forth by your insurance carrier may apply. Please note that payments for dental services are usually due on the day services are rendered if you don’t have insurance or within 30 days of receipt of a statement from us, unless you have made specific arrangements with our office.

Initial:*

We accept all PPO insurance plans. However, we are out-of-network with MOST insurance plans. It is YOUR responsibility to know your insurance plan coverage and in or out of network differences. Please contact your carrier for details and information. You will be responsible for all charges not paid by insurance. Thank you.

Initial:*

Electronic Communication

Our office uses email and text to communicate with you regarding appointments and office/patient needs. For your privacy, we do not send out detailed dental/health/financial information. I agree to electronic communication with the dental practice at the email/text below. I am aware that there is some risk that unencrypted emails may be viewed by third parties. I am responsible for keeping the email address or cell number on file current and I reserve the right to terminate electronic communication with the office by calling 650-344-7888.

Patient Signature:*

Date:

Date