PATIENT PRIVACY – Our NOTICE OF PRIVACY PRACTICES (posted on our website) details how we may use and disclose your protected health information. You have the right to review and request explanation of the terms prior to signing this form and a copy will be provided to you. Our office will communicate via phone directly with you for appointments or any necessary medical and dental information including x- rays and other test results. If we are unable to reach you directly, your signature gives us consent to communicate via answering machine, voicemail, electronic communication via fax, email or through another person and you agree to absolve Primary Dental Ltd and their staff of any liability should that information be received in error by a third party. You have the right to revoke this consent in writing, except where we have already made disclosures in reliance on your previous consent. You have the right to refuse to consent / sign the privacy information. Cell phone use and video recording is restricted in treatment room.
FINANCIAL POLICY – Insurance companies rarely reimburse the full amount. We can estimate your coverage in good faith but cannot guarantee coverage due to complexities of dental insurance contracts. If payment is not received within 60 (sixty) calendar days from your insurance company, then the outstanding balance will be your responsibility and must be paid in full. Deductible and Estimated portion for dental services are due at the time of service. In cases of divorced parents, the parent bringing the child will be deemed responsible for payment. We reserve the right to charge a $25.00 (twenty five) fee for any returned bounced checks.
For non paid dues beyond 60 (sixty) calendar days, additional interest at the rate of 1.5% per month or 18% APR will accumulate. In the event we need to make use of services of an attorney or a collection agency all pertinent information will be sent to that service. Fees incurred to collect payment will be billed to and payable by the patient’s account holder.
CANCELLATION POLICY – Scheduled appointments are reserved especially for you. In the event you would like to reschedule please call us in a timely manner, 48 hours notice is greatly appreciated.
RELEASE OF RECORDS – A written request and a fee is required for transfer/release of records. Please allow for 7 business days to complete your request.
DENTAL RECORDS – I give permission to utilize X rays, photographs, models, video, or audio recordings for the purpose of education, postings on website and or other media. I may cancel this authorization to the extent allowed by law.
COMMUNICATION FROM OUR OFFICE – We will attempt to contact you via email, text message, voicemail, contact member of the family and USPS or Certified mail.
TREATMENT OF MINORS – I understand that if a minor is being treated for any dental service, parent or legal guardian must stay on premises at all times and also that no other minors will be allowed to accompany them in the operatory during their treatment.
DISMISSAL POLICY – Multiple missed appointments, non compliance of recommended treatment, prescription drug abuse, abusive behavior, non – payment of dues and any other serious issue as determined by this office may result in dismissal from the dental practice. We reserve the right to charge $50.00 fee for no show / broken appointment. I have read and agree to the above policies.