Financial Arrangements, Patient Responsibilities & Insurance Guidelines

1. For complete and accurate records, we respectfully request you to please complete all patient intake & information forms prior to examination. Please provide Photo ID and if applicable your insurance card.
2. To provide complete, expert care at fair and reasonable fees, payment is required at the time of service unless a prior financial arrangement has been made. For your convenience, Cash, Checks, Visa, Mastercard, American express. If you need to make long term payments, we can offer financing with Care Credit. One of our team members is happy to help you fill out an application. You must qualify to use this financing option.
3. I understand that the use of local anesthetic agents embodies certain risks and consent to their use as deemed appropriate by Florida Dental Implant Institute Patients under the age of 18 must be accompanied by a parent or guardian. The parent or guardian is responsible for payment at the time of service. We cannot be bound by any divorce or other family relationship contract. Patients 16&17, who have started orthodontic treatment are the exception.
4. We care and will work out financial plan for you. In good faith, you must stay current with any financial arrangements. Any account 60 days past due will be turned over to an outside 3rd party collection agency whereas you will be responsible for collection cost, returned item fees and any unpaid charges. In the event of default, I agree to any legal interest on the indebtedness required to effect collection of my account.
5. You will enjoy the benefits of our multi-specialty practice and expert care. Due to the high demand for our dental & specialty services, financial arrangements are necessary to reserve your appointment time. We understand life happens and schedules change. Therefore, we respectfully request a 48-hour notice in order offer this appointment time to other patients awaiting treatment. Failure to show or canceling without proper notice will result in a charge of $100 per hour booked. Since many dental conditions rapidly deteriorate, treatment plans/fees are valid for 30 days. Afterwards, a new oral exam and treatment plan may be necessary to update changes in your dental/medical health and fees.

For Patients with Insurance

For our patients with Insurance, it is important to remember that insurance is a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. As a courtesy to you, our highly trained and experienced staff will gladly estimate your insurance coverage & file your primary insurance.

It is important to understand that: Your dental benefits are a contracted benefit between you, your employer and the insurance company

• PPO Fe schedules are constantly updated. PPO fees are estimated from existing fees schedules that may not reflect updated fees, coverage. If a PPO fee schedule has increased coverage or decreased coverage, the most current, updated PPO schedule will prevail.
• We will provide a written treatment plan with an estimation of your insurance coverage/benefits as well as provide written estimate of services / material not covered by insurance.
• However, insurance portions are estimates only and you are ultimately responsible for professional fees for services rendered.

Florida Dental Implant Institute will work with you in accordance with the HITECH Act (aka the Health Information Technology for Economic and Clinical Health Act, as your patient advocates, we will work on your behalf to maximize your insurance coverage/benefits. Necessary non covered procedures and material fees will not be billed to insurance as they may interfere with benefit coverage for covered services. Free, discounted and case fees courtesies cannot be combined with insurance or any other promotions. Discounted case fees are based on cash/noninsurance coverage. For covered services, our Usual and Customary full fees will be billed to insurance and if reimbursement exceeds reduced fee estimates or exceeds total case fee quoted, the difference will be applied towards actual services rendered to you. Unfortunately, insurance companies, at their discretion can pay, downgrade or deny coverage based on their interpretation your insurance contract. If your claim is not disbursed within 60 days of services rendered, you are responsible for balance. By signing below, you acknowledge that you have read, understood and consent to our payment and insurance policy and authorize Florida Dental Implant Institute to maintain and store my health records in accordance to HITECH Act.

I certify that I have read and understand the above information and have accurately answered to the best of my knowledge. My signature confirms that I have informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 HIPAA. I understand that this information can and will be used to: (1) Provide and coordinate any treatment rendered to me or my child among several healthcare providers who may be involved in that treatment directly and indirectly. (2) Conduct normal healthcare operations such as quality assessment and improvement activities. I give my permission to share my information electronically. I authorize and request my insurance company to pay directly to the dental practice insurance otherwise payable directly to me. I understand that my insurance carrier may pay less than the usual bill for the services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that I may request in writing that you restrict how my privacy information is used or disclosed to carry out treatment, payment or healthcare operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Please note that by signing this form you authorize us to call, text, e-mail, and / or leave a message regarding any appointments scheduled. I,have also reviewed the privacy policies of Florida Dental Implant Institute Care.