Secondary Number

Group Name

Secondary Number

Group Name

We respect your time and do not “double-book” appointments. When you schedule an appointment with us, this time is reserved exclusively for you. Any change in the appointment affects many people. If you are unable to keep your appointment, please give us as much notice as possible, preferably 48 hours, so that we may offer this time to another patient. We may charge up to $25 per half hour that we are unable to use as a result of a broken or cancelled appointment.

Renaissance Family & Cosmetic Dentistry prepares a Treatment Plan Estimate so that patients can understand the estimated costs of their recommended treatment prior to its start. The Treatment Plan Estimate is a good-faith attempt to predict the cost of your treatment based on the facts known to us when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you that different or additional treatment is necessary and your financial responsibility may change. If you have dental insurance, it is important to understand that your actual insurance benefits may differ from the benefits estimated in your Treatment Plan Estimate. Your Treatment Plan Estimate of insurance benefits is based on information provided by your insurance company and by you. It is an estimate and your insurance benefits may be higher or lower than estimated. In all cases, you are responsible for amounts not covered by your insurance, unless prohibited by law or contractual agreement. A Predetermination of Benefits is not a guarantee of coverage. In all cases, we encourage all patients with insurance to refer to their member handbooks or to call their plan administrators with any questions or concerns relating to specific benefits.

If you have insurance benefits, you may have the option to seek a Predetermination of Benefits before you proceed with any treatment. Predetermination of Benefits is a process whereby your insurance company or plan administrator tells you in advance of treatment what procedures may be covered by your insurance plan, the amount the insurance company may pay toward those procedures, and the amount you may be required to pay. Requesting a Predetermination is like submitting a claim before the dental procedure or service has taken place.

Because the Predetermination comes directly from your insurer or plan administrator, the risk of error as to your coverage is reduced. If your treatment includes extensive or complex services, such as bridges, crowns, dentures or periodontal work, a Predetermination may be particularly helpful to allow you to appropriately budget for the services or discuss any potential alternative treatment that may be available, if necessary.

The Predetermination of Benefits process gives you useful information about what services may be covered. However, your insurer will inform you that a Predetermination of Benefits is not a guarantee of coverage. A Predetermination sets forth your expected benefits based on the information available to the insurer at the time the Predetermination is prepared. The Predetermination may not consider, for example, a prior claim submitted by another dentist for services provided to you, changes in your coverage that occur after the Predetermination is made but before the services actually are provided, or the insurance company’s subsequent opinion that a condition could have been treated by a less costly alternative to the service provided by your dentist.

The time it takes to receive a Predetermination from your insurance company or plan administrator can vary, from as few as two weeks to as many as eight weeks. The decision to seek a Predetermination of Benefits or to proceed with treatment immediately is your own unless your plan requires otherwise. Please inform the Practice Coordinator if you would like to request a Predetermination of Benefits from your insurer.

In all cases, Renaissance Family & Cosmetic Dentistry patients agree to the following payment policies:

• Payment in full of the estimated patient portion of the fees is due no later than when services are rendered.
• For comprehensive treatment plans requiring multiple office visits and implant services, we require a minimum deposit of 50% of the total estimated patient portion of the fees at the start of treatment.
• Patients are always responsible for amounts not covered by insurance, regardless of whether the original estimate included an expected insurance benefit, unless prohibited by law, or unless RFCD has a contractual agreement with my plan prohibiting all or a portion of such charges.
• Patients may, at their discretion, elect to pay in full, in advance for comprehensive treatment plans. Refunds for unused credit balances will be issued pursuant to our refund policy as stipulated in section IV, below.
• Patient will incur a $35 charge for each returned check. Any balance left unpaid for more than 30 days will be subject to interest charges at the rate of 1.5% per month .

Renaissance Family & Cosmetic Dentistry will refund any amount paid for treatment that you did not receive, except for RCFD’s policy for Interrupted Services as set forth below. Also no refunds will be allowed for purchased products or services like teeth whitening, night guards, splints, diagnostic casts and wax ups, processed dentures.

Patients requiring crown or bridge services (not including implant) may cancel treatment with no charge prior to natural teeth being prepared or altered for the prosthetic. Once tooth preparation occurs, patients are liable for the estimated full cost of the services even if they choose not to complete treatment.

I consent to the performing of dental procedures deemed to be necessary by the doctor. To the best of my knowledge this paperwork has been accurately answered. I will bring all future changes in my medical history to the attention of the doctor. I understand that providing incorrect or incomplete information can be dangerous to my health. I grant my permission to you or your assignee, to telephone me at home or at my work, or to send text messages or e-mails, to discuss matters related to this form and my oral health. I understand that during the course of treatment, certain unforeseen conditions may be revealed that may necessitate extension of the proposed procedure or a change from what was previously noted. If that occurs, I authorize the doctor and staff to perform such procedures as necessary and desirable in the exercise of professional judgment and I will be responsible for any associated fees. I authorize my insurance benefits to be paid directly to Renaissance Family and Cosmetic Dentistry. I understand and agree to the above conditions of treatment, the Notice of Privacy Practices, and the office Financial Policies and will be responsible for payment of my treatment. I authorize the doctor to release any and all photographs taken of the previously name patient for teaching purposes, for educational journals, and for marketing purposes.

We at Renaissance Family & Cosmetic Dentistry are required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Age

Date

Physician’s Phone

How long ago was last visit?

How often do you floss?

PLEASE CHECK YES OR NO FOR THE FOLLOWING :

Has your present denture been relined? When

Is your present denture a problem? Describe

Satisfied with the appearance?

Satisfied with the comfort?

Satisfied with the chewing ability?

When did you receive your first partial or complete denture?