Thank you for taking the time to read through the following few paragraphs. We are required by law to present you all this information. I ask that you review each and every item listed below. If you have any questions regarding any of the information provided for you below please ask.
You will be asked to sign your name at the end and by doing so you understand and agree to all the terms. Again, thank you for your cooperation.
1) MEDICAL AND DENTAL HEALTH FORM
I affirm that the information given is correct to the best of my knowledge. I understand that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I understand that providing incorrect information can be dangerous to my health.
I authorize the dental staff of the Duvall Dental Center to perform the necessary dental services I may need.
2) INSURANCE AUTHORIZATION
Disclaimer: Duvall Dental Center strives to provide accurate estimates for services to the best of our ability. Treatment plans are estimations only and it is always in your best interest to contact your insurance company to verify plan coverage.
I certify that I am covered by an insurance company and hereby assign directly to Dr. Castillo all insurance benefits, otherwise payable to me. I understand that I am responsible for payment of services rendered. I AM ALSO RESPONSIBLE FOR PAYING ANY CO-PAYMENT AND DEDUCTIBLE THAT MY INSURANCE DOES NOT COVER AT THE TIME OF SERVICE. I hereby authorize the Duvall Dental Center to release all pertinent information needed to secure the payment of benefits. I authorize the signature at the bottom of this page for all my insurance submissions whether manual or electronic.
3) FINANCIAL RESPONSIBILITY
Payment in full is expected at the time of service.
4) PRIVACY ACT
I have received and read a copy of this office’s Notice of Privacy Practices. I understand that if I don’t understand anything about this privacy act I may ask the office manager of this facility.
5) NITROUS OXIDE USAGE
This office does supply nitrous oxide to patients who request it. As you know N202 is a drug and it cannot be administered to anyone with diminished lung capacity. Anyone with COPD should not be administered nitrous. THIS OFFICE DOES CHARGE FOR THE ADMINISTRATION OF NITROUS OXIDE.
6) FAILURE TO SHOW UP FOR RESERVED APPOINTMENT
In the event that you are unable to make your reserved appointment you are required to call us 48 hour in advance to cancel the appointment. THIS OFFICE DOES CHARGE A $68 FEE FOR A MISSED OR FAILED APPOINTMENT.