The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
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 dental history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.
Our PhilosophyIt is important to us that the quality of our business services matches the quality of our dentistry. We want the handling of your account, from the start through final payments, to be perceived as an extension of the dental care we provide you and your family.
Patient’s RoleAs with any partnership, both parties have a role to play. Our role is to provide you with quality service. In turn, your role is to pay for your treatment in a timely manner. Our team will work with you to determine financial arrangements that make sense for both of us. With an agreement made, our joint follow-through will result in a win for everyone.
Forms of payment:
Extended Payment Plans with Credit Approval:
CareCredit www.carecredit.com 800-677-0718
Regarding InsuranceAs a service to our patients we will file and take assignment of your insurance benefits. We will carefully estimate your personal investment for your dental care and make every effort to maximize your dental benefits. This is an estimate only. We cannot make any guarantees as to your insurance coverage. It is impossible to determine what the actual benefit for any service will be. All deductible, co-pays, unpaid insurance balances are the responsibility of the patient/responsible party.Please review and sign the Dental Insurance Disclaimer.
Thank you for understanding our Financial Alliance. Please let us know if you have any questions or concerns.
I have read the Financial Alliance. I understand, accept, and agree to this Financial Alliance.
Please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment, we at no time guarantee what your insurance will or will not do with each claim.
Our goal is to help you maximize your dental insurance benefits. We are happy to bill your dental plan for services. When we call on your insurance and verify benefits it is not a guarantee of payment by the insurance company and reimbursement may vary according to your individual plan when the actual claim is submitted. Any treatment plan that our office proposes to you is an estimate of your insurance coverage it is not a guarantee. We will always work to maximize your insurance benefits for you.
Please remember that the contract itemizing your dental benefits is between you, your employer and insurance company. Although we call and get benefit information for you we suggest that you call your insurance company to confirm any waiting periods, deductibles or benefits payable concerning your treatment plan. Regardless of coverage, your estimated co-payment is due in full the day of treatment. If your insurance plan does not pay within 60 days of treatment, you must pay and outstanding balance and seek reimbursement from your dental plan. Also remember dental insurance plans are not designed to cover all of your dental needs.
To Read and Sign
I have chosen to allow Dr. Groat to file my insurance and I do accept full responsibility for this account and for all dentistry performed upon my family in this dental office. I also understand this office cannot guarantee my insurance company will cover all services rendered and it is only an estimate of benefits. I also understand that if my insurance company does not pay within 60 days of my date of service then I will become responsible to pay at that time.
The known limitations of my plan have been reviewed and applied to this estimate.
Because mutual understanding is the basis for good relationships, it is important for you tounderstand the nature of our office policies related to appointments.
1. Notice of Privacy Practices
I acknowledge that I have received the practice’s “Notice of Privacy Practices”, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s “Notice of Privacy Practices”.
2. Acknowledgment of Dental Materials Fact Sheet
I acknowledge that I have received and read “The Facts About Fillings” prior to starting restorative dental work at David A. Groat, D.D.S.
3. Acknowledgment of communication
I authorize Dr. Groat and his staff to communicate with me via Email, Cell Phone or Text