Please read the following Chandler Family Dentistry policy and acknowledge your acceptance by signing below. As your dental care provider, our relationship is with YOU and NOT your insurance carrier. We will file your claim with your insurance company as a courtesy to you. However, you are the sole responsible party for all charges incurred and must guarantee payment. We kindly ask that payment be made in full at the time of service, regardless of insurance status. We’re happy to  submit your claim to your insurance provider.

Please acknowledge that the medical health history information provided is accurate and complete.

As your dental care provider, Chandler Family Dentistry strives to provide the best possible care using state-of-the-art techniques in a welcoming and safe environment. We do our utmost to provide accurate cost estimates for dental procedures. Please do not hesitate to ask questions or discuss your concerns with our knowledgeable and helpful administrative staff.

Our fee schedule reflects a combination of usual and customary fees and local fee surveys. It also factors in time spent, the complexity of the procedure, supplies used, and lab fees. At a minimum, fees are evaluated on an annual basis. Chandler Family Dentistry does not send monthly statements.

We expect payment in full for services when performed.

I assume full responsibility for all charges incurred. I understand and acknowledge that if my dental account becomes delinquent, I will be responsible for payments of all unpaid balances, including but not limited to, finance charges, returned check charges, collection fees, court costs, and attorney fees.

Please acknowledge your acceptance by signing below.

There are almost as many insurance plans as hours in a year. Insurance reimbursement for dental procedures can be confusing. As a courtesy, we will file your insurance claims so you may receive all the benefits you are entitled to under your plan. However, it is prudent to be fully informed about the parameters of your coverage.

Employers often provide insurance. Discuss your coverage with your employer or seek guidance from a plan representative. Many employers offer multiple plans; benefits can change yearly, as do co-pays and deductibles. Unfortunately, insurance companies often bundle or deny services that they feel are unnecessary or should be categorized differently. The contract between the insurance company and your employer or your insurance company and you determines fee reimbursement.

I authorize the release of any health information necessary for processing of insurance claims by Chandler Family Dentistry. I authorize payment of any insurance claims due to Chandler Family Dentistry to be paid directly to her. I authorize Chandler Family Dentistry’s staff to affix my signature on any dental insurance forms for myself and my family for the next five years beginning as of this date. A copy of this authorization will be valid as the original.

Please acknowledge your acceptance by signing below.

Chandler Family Dentistry strives to provide excellent dental care to every patient, and scheduling adequate time with each patient contributes to that high level of care. However, when a scheduled appointment is missed without proper notice, it creates a lost opportunity for the practice to treat another patient.

THE CHANDLER FAMILY DENTISTRY APPOINTMENT CANCELLATION POLICY:

We require that you give our office 48 hours’ notice if you need to reschedule your appointment. That allows for us to schedule another patient in your slot.

A $75.00 “missed appointment” fee will be charged to your account if you do not contact our office 48 hours before your scheduled appointment. A “missed appointment” fee cannot be billed to your insurance company. Payment of this fee is your responsibility and must be received before future appointments are scheduled.

Reach out to our staff if you have any questions regarding this policy. They will be happy to address your concerns. Chandler Family Dentistry values every patient, and we appreciate the confidence you place in us as your dental care provider.

Please acknowledge by signing below that you have read and understood the Chandler Family Dentistry Appointment Cancellation Policy and agree to be bound by its terms. You also agree that the practice may amend such terms at any time.

I am aware of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191HIPAA Privacy Practices set forth by the government and followed by Chandler Family Dentistry.

I request and authorize the doctor listed below and practice to release dental/health care records on the following patient to Chandler Family Dentistry/Dr. lrina Chandler, DDS, 253 Main Street, Warsaw, Virginia 22572, 804-333-0226.

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know canceling this authorization would not prohibit any release of information by the doctor or practice relying on my original authorization.

There are two ways to cancel this agreement:

• Sign and date a form available from the Doctor or Practice called “Revocation of Authorization for Use and Disclosure of Health Care Information.”
• Write a letter to the Doctor or Practice. If I write a letter, it must say that I want to cancel my authorization to disclose my Health Care Information. I (or my authorized representative) must sign and date the letter.

Once my doctor gives out the information I want to release, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.

Please acknowledge by signing below.

With your consent, Chandler Family Dentistry will email and/or text you appointment reminders and dental care updates. Please note that text and email communications from Chandler Family Dentistry are NOT encrypted, and therefore, may be at risk, however minimally, of inappropriate access. We will never share your email address with third parties.

Please acknowledge by signing below that you understand your communication instructions will remain in force until you update Chandler Family Dentistry in writing.