Financial Arrangements & Policy

Thank you for choosing our office for your dental health needs. Dr. Rainey, Dr. Fritsche and our team are committed to your treatment being successful and pleasant. The following is a statement of our Financial Policy which we ask that you read and sign prior to treatment.

Our methods of payment accepted includes Cash, Personal Checks, Mastercard, Visa, and Discover credit card payments. We now offer Care Credit & Lending Club. Financing allows no interest payments for your dental care needs. If you have any questions, please feel free to ask.

Initial

• ________ Missed Appointments:
Please be aware that when scheduled appointments are missed by either no-showing or without a 48 hours (2 days) notice, the patient’s account may be assessed a $100 fee. This fee is not covered by insurance, and will need to be taken care of prior to scheduling your next appointment. Thank you in advance for committing to your appointed time with us!

• ________ Regarding Your Insurance:
As a courtesy to you, we will help file your dental insurance. In order to help you, we will need to complete insurance information in order to bill your insurance company. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please understand that there are many different insurance plans. Payment is determined at the time the claim is received by the insurance company. Dental insurance is only meant to assist you, and not to pay for the completion of your dental care. We can only estimate what your insurance will help you cover. We do the best we can with the information the insurance company gives us. This is not a guarantee of payment. If your insurance company has not paid your account in full within 45 days, we require you to pay the balance in full by the methods above. In the event that your coverage changes, our office must be notified at least 2 business days prior to your appointment to ensure proper verification.

• ________ Usual and Customary:
Our practice is committed to providing the best treatment for our patients and we charge our usual and customary fees to all of our patients. Ultimately you are responsible for the payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Your policy may base its allowances on fixed schedule, which may or may not coincide with our usual fees. Usual and Customary fees by your insurance may be based from the average practitioner in an average office with average staff. We sincerely believe our office is far above those guidelines.

The adult accompanying a minor and the parents (or guardians) are responsible for full payment.

I understand and agree that all services rendered to me, my dependents, or others assigned by me to my account are charged directly to me. I further understand I am personally responsible for payment. Should the fees for the professional services not be paid in accordance with the provisions herein, applicable finance charges and disbursements, allowances and cost can be applied to all past due amounts at the rate of 1.5% per month (18% annual rate.) If the account is in default and turned over for collection, a collection fee will be added.

name of patient (& parent/guardian)

Signature & Date

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.

DATE: Will Be Automatically Filled from first step

The undersigned acknowledges receipt of a copy of currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/ FACILITIES IN THE FUTURE.

Please print name of Patient Please sign

_______________________________

Please list any other parties who can have access to your health information:
(This includes step parents, grandparents, spouse, siblings or any care takers who can have access to the above named patient’s records)

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Patient No-Show and Cancellation Policy

We strive to provide excellent and prompt dental care to all of our patients. In order to be consistent with this, we have adopted a Patient No-Show and Cancellation Policy for our office. When an appointment is scheduled, that time has been reserved for you. However, when you do not cancel or no-show to your appointment, it prevents another patient from getting much needed treatment.

Our policy is as follows: You may cancel your appointment up to two business days before your scheduled appointment with no consequences. We will be happy to reschedule the appointment for you and leave the open time for another patient. If you miss your appointment or cancel less than two business days before your appointment, Comprehensive Family Dental will charge $100 for each no-show or late cancellation. This fee is the patient’s responsibility and is not billable to insurance.

Additionally, if a patient is more than 15 minutes late to his/her appointment without prior notification, we reserve the right to cancel or reschedule the appointment.

We do realize that, on occasion, emergencies or circumstances may arise beyond your control. We will address these situations with you should that occur.

We thank you for working with us to ensure that we are able to provide the best service possible to all of our patients.

I have read and understand the Patient No-Show and Cancellation Policy and I agree to the terms.

Patient Name Printed: ____________________

Date of Birth:

Patient Signature: ____________________

Date: ___________________________

Patient PaperWork

Last Name

First Name:

Middle Name:

Preferred Name:

Birthdate: Will be used from previous Step

S.S#

Patient Address:

Email:

Home PH:

WK Phone:

Cell Ph:

Occupation/Grade/Major:

Employeer/School:

How did you hear about our office?

Spouse's Name:

Emergency Contact

Phone:

For All children (Under 18)

Father's Name:

Occupation:

Work Ph:

Father's Name:

Occupation:

Work Ph:

Patient Lives With:

Insurance Information

Subscriber's Name:

Birthdate: Will Be used from previous Step

Social Security Number:

Relationship to patient:

Employer:

Work Ph:

Insurance Company:

Insurance Company Ph:

Member Id Number:

Group Number:

DENTAL HISTORY

What is your reason for seeking dental treatment?

What was done then?

Any Teeth Sensitive to?

Do Your Gums Bleed?

Does Food catch any place? Where?

Do you have bad breath?

Do you clench or grind your teeth?

When:

Prior orthodontic treatment?

Were permanent teeth removed for orthodontics?

Any soreness in your teeth or jaws on waking?

Do you wear a nighttime appliance?

Do your jaws click when you chew or open wide?

Did you now, or have you ever had, pain in your jaw joint or the sides of your face?

Do you like your smile?

What would you change?

Do you have any fear of having dentistry done?

If yes, Why?

I, Your Name Already Provided in previous step (patient),
authorize Dr. Tim Rainey, Dr. Donnese Fritsche and Comprehensive Family Dental, to take photographs, and / or videos of my face, jaws and teeth, before, during and after treatment.

I consent to allow the photos the be used for the following:
⦁ Dental Records
⦁ Dental Research
⦁ Dental Education including lectures, seminars, demonstrations, professional publications such as journal or books
⦁ Marketing material, including websites and printed materials, patient education

I do NOT expect compensation, financial or otherwise, for the use of these photographs.

Aggree Check here if you do NOT want your full face shot used for any of the above purposes

Patient Signature:_________________________________________________
Patient Birthday: Will Be Used From Previous Step
Today’s Date: Will Be Used From Previous Step

New Patient Packet

Financial Arrangements & Policy

HIPAA OMNIBUS RULE

Patient No-Show and Cancellation Policy

Patient PaperWork

DENTAL HISTORY

PLEASE ANSWER EVERY QUESTION

ADDRESS

PHONE

(361) 573-7722

HOURS