New Patient Intake Forms & Guidelines

NEW PATIENT INTAKE FORMS

Below are our new patient intake forms. Please print and complete these forms prior to your appointment, and feel free to contact us with any questions or concerns. We look forward to seeing you soon!

Cancellation Policy

We realize that things come up unexpectedly.  A rescheduled appointment may be valuable to another patient, so we ask that you notify our office 48 hours in advance if it is necessary to reschedule an appointment . A $50 cancellation fee will be charged if special circumstances do not apply.

 

Dental Insurance

For patients in good standing (with the exception of non-residents), this office will except assignment of benefits from our patients’ insurance carriers for dental services provided. A claim will be processed for those individuals with non-assignment plans so they may receive reimbursement from their insurance carrier.

Patients who do not have insurance coverage or who have insurance carriers who do not honour assignment, must provide full payment on the date of the appointment; unless prior arrangements have been made.

Most insurance claims are now sent electronically, not requiring a patient’s signature. For those claims that cannot be sent electronically, it is the patient’s responsibility to ensure all paperwork is completed and signed.

The patient portion owing on the claim must be paid on the date of the appointment when the insurance carrier provides that information on an electronic claim response.

When an electronic claim does not provide the patient portion owing on the claim, or if a claim cannot be sent electronically, the following will apply:

  1. The patient portion owing will be estimated at 20% of all claims generally considered “basic” and is payable on the date of the appointment.
  2. The patient portion owing will be estimated at 50% of all claims generally considered “major” and is payable on the date of the appointment.

All insurance payments must be provided within 45 days. If the insurance carrier does not provide payment within 45 days, the patient is responsible for the payment and must seek reimbursement from their insurance carrier.

Individual insurance policies vary in regards to personal coverage and fee schedule guidelines. It is the patients responsibility for all knowledge regarding their personal coverage. Preauthorizations for specific dental services will be sent to the insurance carrier “when requested by the patient.”

Special Circumstances

Our foremost concern is the dental health of all of our patients. Special financial arrangements can be made with our office manager when the cost of dental care will cause financial hardship.