ARFD NPF

Patient Informaton

Dr. Tina Nichols | Dr. Samaria Mascagni
Name *

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Referral Information
Whom may we thank for referring you to our practice?

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Employment Information
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Financial Policy (for all patients)

Thank you for choosing us as your dental care provider. The following describes our Financial Policy. Our office is committed to providing you with the best possible care. Your understanding of our financial policy is an essential element of your care and service. If you have any questions regarding any aspect of our policy, please feel free to present your question to any of our team members.

Payment for services is due at the time services are rendered. We accept cash, debit card, and for your convenience Visa, MasterCard, American Express, Discover and 3rd party financing through Care Credit and Lending Point.
Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service. Payment in advance may be required for certain treatment in order to reserve chair time and fund dental laboratory fees.

Deposit Policy:

Due to the extensive amount of time our staff and doctors devote to preparing and reserving uninterrupted time for appointments of an hour or more, we require a deposit of half of the treatment fee to make your reservation.   Initial Here*

Appointment Policy (for all patients):

We will work hard to accommodate appointments that fit your schedule and dental needs. We ask that you let us know about changes 48 hours in advance. We do understand that life happens, but any missed appointment without the 48 hour call may be subject to a $50 short/no notice fee, habitual missed appointments are grounds for dismissal from the practice.   Initial Here*
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. We neither accept third party assignments nor do we recognize or enforce the terms of divorce or child support decrees.

I have read and understand the Financial Policy and Appointment Policy for Arkansas Family Dental. I agree to abide by these policies.

Insurance Policy and Assignment of Benefits (for patients with dental insurance only)

As a courtesy, we will file the forms necessary to see that you receive the full benefits of your coverage. Because your insurance policy is a contract between you, your employer, and the insurance company, it is your responsibility to make sure we have accurate and up to date insurance carrier information, restrictions of your policy, and billing information. If your insurance company has not paid your claim in full within 45 days the remaining balance will automatically become patient responsibility.   Initial Here*

Please be aware some and possibly all of the services provided may NOT be covered by your insurance provider. Services, which are not covered, downgraded or fall under L.E.A.T (least expensive alternate treatment) by your insurance are your responsibility. Any balance left unpaid after 30 days will be sent to collections, these accounts will accrue a $50 delinquency fee in addition to any past due balance.Initial Here*

I hereby authorize my primary and/or secondary insurance company to make payments directly to Arkansas Family Dental. Furthermore, I have read and understand the
Insurance Policy for Arkansas Family Dental. I agree to abide by these policies.
Initial Here*
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with the office late fee, as well as current office procedures as outlined in the above text. *

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Date *

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Relationship to Patient

Arkansas Family Dental HIPAA Consent Form

Tina H Nichols, D.D.S. | Samaria Mascagni, D.D.S.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out the following:
- Treatment (including direct or indirect by other healthcare provides involved in my treatment)
- Obtaining payment from third party payers (e.g. my insurance company)
- The day-today healthcare operations of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of the notice from time to time and that I may contact you at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and discussed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at anytime. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

Arkansas Family Dental Office Policies

Office Financial Policy

Payment is due the day of service. As a service to our patients we will file your dental insurance for you. As long as your insurance can be verified, you will only be responsible for your estimated percentage of treatment on that day of service. We can only give and estimate of what insurance will pay, any remaining balance is your responsibility.

48 Hours Notice Policy

It is very important that we receive notice of a change in plans at least 48 hours in advance. This gives us the chance to schedule another patient in your place. If we do not have sufficient notice regarding a schedule change, we will be unable to care for another patient in need of our services.

Arkansas Family Dental is sure that you understand why we must have policies along these lines. It is our policy to charge a $30.00 missed appointment fee to any patient that cancels their appointment the day of the appointment.

I understand that by signing this agreement I am expected to adhere to the policies set forth within this notice.
Name *

First Name Middle Name Last Name
Date *

Month Day Year
Relationship to patient
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with Arkansas Family Dentals HIPAA Consent form and all information held therein. *

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Patient Informaton

Referral Information

Health Information

Employment Information

Insurance Information

Parent or Guardian Information

Arkansas Family Dental HIPAA Consent Form