IT IS REQUIRED OF YOU TO READ EACH SECTION, INITIAL AND DATE I also understand that the NOTICE OF PRIVACY COLLECTIONS PRACTICE specs are presented in a binder in our waiting room for you to review. If you would like a copy please Over the past few years, there have been an extremely ask at the front desk. significant number of incidences where patients opt not to pay their dental bills. If payment is not RECEIVED in office within 30 days your unpaid balance will incur a $2.00 a month “billing” charge. In the event that I, ______________________________________________ payment is not RECEIVED in office within 90 days after authorize_______________________________________ services have been fulfilled to you or the person(s) you are jwill be suspended. ________________________________________________ You or your family’s dental needs are our #1 priority. ________________________________________________ Payments for work facilitated should be your #1 priority. to discuss my treatment plan. Please keep in mind, as our office grants you a 90 day grace period after services are rendered; however after 90 days our office utilizes ZERO TOLERANCE contra 3 Signature Of Patient / Parent or Guardian Date patient payment discrepancies. Other collection protocol utilizes an array of collection ARE YOU AN INSURANCE PATIENT? If resources to report delinquency after 90 days, as well as YES, I understand that my insurance company will NOT collections attorneys, not a collection agency, to recover pay 100% for my dental needs or for my dependents. compensation for work facilitated. Thus it is mandatory I understand that when using my insurance that I am for our office to make a copy of your driver’s license responsible to keep up with my Explanation of Benefits prior to seeing the doctor. (EOB), Eligibility, and Policy Limitations regarding my I understand that I will be honest, righteous and forthright own insurance coverage. to make my payments. If I am not able to make payments I will ask to set up a monthly payment plan as to avoid the I UNDERSTAND MY INSURANCE COVERAGE IS COLLECTION protocol. Initials BROKEN INTO PROPORTIONAL SEGMENTS AS: Of Patient / Parent or Guardian __________________ 1 PREVENTATIVE 100%/ BASIC 80%/ MAJOR 50% - COVERAGE. *The percentage provided my not reflect your actual coverage but is the average for nearly 90% of NSF & STOP PAYMENT OF CHECKS dental coverage In the State of Florida writing a check that does not have If payment is not made when you are billed our office may the funds to post payment for the check is a CIVIL suspend your account. Keep in mind that you may have an violation of Florida State Law and we are obliged under out of pocket expense with your services sate law to report these violations. You will be charged $30.00 for any check that is NSF and your case will be If you do not have insurance listed below you must pay for immediately forwarded to Flagler County DA’s office services at the time they are facilitated. If our office does (John Turner). The DA will then prosecute you on behalf not hold a network contract with your company our office of the state. All attorney and court costs will be your will not be mailed an insurance check. responsibility. Stopping payment of a check is a CRIMINAL violation I understand the provisions clarified to me regarding my which may be processed as a 1st degree misdemeanor or a financial responsibilities and personal / family insurance felony. If you put stop payment on a check please notify us management. I understand that if my insurance doesn’t pay first to make alternate arrangements for payment. We ARE for services, I’m responsible for the difference required by state law to report checks that were STOPPED Initials________________ WITHOUT ALTERNATE ARRANGMENTS MADE FOR PAYMENT to Flagler County Sheriff’s office. Of Patient / Parent or Guardian 4 PLEASE DO NOT STOP PAYMENT OF YOUR CHECK WITHOUT NOTIFYING US. I understand and agree that (regardless of my insurance status). I am ultimately responsible for the balance of my 2 I understand the severities of ill managed check writing account for any dental services rendered. If my account and the consequences of facilitating such an action should become delinquent in arrears and sent to collections, I Initials________________ AGREE to pay for all collection costs, Attorneys costs and Of Patient / Parent or Guardian 2 court costs in order to collect my debt EACH time I have a visit within the office for not only myself but for any dependents. HIPPA By signing this you understand that our office upholds all Signature Patient /Parent or HIPPA laws that basically state that your private “patient” Guardian______________________Date_________ 5 information will not be shared with any 3rd parties other than a doctor, or Health Care Provider or Business PLEASE SIGN / INITIAL IN BOXES Associates catering the welfare of your account 1 THROUGH 5 OR THIS FORM HAS NOT BEEN COMPLETED!