Patient Information

PRIMARY

SECONDARY

I cerify that I, and/or my dependent(s), have insurance coverage with the company/companies listed above and assign directly to Dunn Family Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. 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 the staff will rely on this informaiton for treating me. 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 the 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. 

Thank you for choosing Dunn Family Dental. We are committed to your successful treatment. Please read and sign this to acknowledge your understanding of our financial policy. 

Changed or Broken Appointments
Because instruments, chair time, and personnel are reserved exclusively for your appointment, there is a $25-$50 CHARGE FOR CHANGED OR BROKEN APPOINTMENTS LESS THAN 24 HOURS IN ADVANCE.

Payment is due at the time of service.
We accept cash, check, visa, mastercard, discover, and american express. 
If you have insurance, the payment of your deductible and estimated patient portion is due at the time of service. 

You and Your Insurance
You have a contract with your dental insurance company. We are not a party to that contract, and while we do our best to obtain information from your insurance company, it is ultimately your responsibility to understand your policy and its limitations. For patients with policies in which we are not in network, you are still responsible for full charges. 

Estimates
We provide an estimate that you should consider a guideline until final insurance payment is received and your account has been reconciled. We make every effort to provide accurate estimates, but our office can make no guarantee that insurance payments will match our estimates.

Claims
Claims are submitted promptly to your insurance company after treatment. Any claim that is not paid after 61 days is billed directly to you.

Predeterminations
At your request, we will gladly process your predeterminations, but please be aware that predeterminations are not a guarantee of payment. 

Unaccompanied Children
If you wish for your child to come alone to their appointment, PRIOR arrangements for payment must be made (cash, check, or credit card authorization). 

Practice Name: Dunn Family Dental

HIPAA Acknowledgement

1. Our Notice of Privacy Practices (NPP) provides information about how our practice may use and disclose protected health information (PHI) about you. Your signature acknowledges receipt of the Notice of Privacy Practices and allows our practice to use and disclose PHI for treatment, payment, and healthcare operations.

2. You may restrict your PHI by making a request of our Privacy Officer. 

 

4. You give permission for the practice to share medical information with:

7. I authorize sharing my protected health information with the following individuals who may be involved in my care and I understand I am responsible to notify the practice of any changes:

8. I authorize the following means of communication: