Please call our office if you have any issues finding our location.

Please complete the enclosed information form before your visit and bring it with you. If you have x-rays or models from a referring doctor please bring them with you.

Our patients are cared for on a “fee for service” basis. Unless other arrangements have been made, payment is expected at the time services are rendered. We will be happy to complete your insurance paperwork and submit it to your insurance carrier for reimbursement to you.

We very much look forward to meeting with you to discuss your treatment needs and desires. We will make every effort to provide you with oral health, comfort and a pleasing appearance. If you have any questions don’t hesitate to call our office.

 

Office Financial Policy:

It is the policy of this office that patient payments are made at the time treatment is rendered. We do not participate in accepting direct payments from insurance companies. We will, however, bill your insurance company for you and assist in determining your insurance benefits. Payment for treatment is the responsibility of the patient.

For services exceeding $500.00, predetermination of insurance benefits is possible. Depending on your carrier, this can take time, but it provides an estimate of what your insurance company will pay for a particular treatment plan. Please remember that predetermination estimates are subject to change if other charges draw from you insurance benefits. This may occur if your original treatment plan changes or if you are seeing other providers.

When treatment is extensive and/or requires a number of visits, we ask that patients pay their portion of the fee as treatment proceeds. We require ½ payment when treatment begins, with the balance due prior to completion of treatment. Your insurance paperwork will be submitted upon completion of treatment, with benefits payable to you.

We offer both interest free (6 months) and extended flexible payment through CareCredit.
Information on these programs can be obtained during your visit or by calling our office.

Fees proposed are in effect for a six (6) month period, after which they are subject to change as fee schedule changes would dictate.

We make every effort to stay on time for your scheduled appointments. Please understand that your appointment is a reserved time for treatment by the doctor and/or hygienist and staff. Unless a 24-hour notice is given, a charge will be made for failure to keep an appointment. If you are unable to keep an appointment please inform us. Other patients will appreciate your courtesy to release time to them.

I have reviewed the above financial policy and agree to these terms and conditions

Welcome to our Practice

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT

SPOUSE OR OTHER GUARANTOR INFORMATION (If different from above)

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY

DENTAL INFORMATION

MEDICAL HISTORY

MEDICATION & ALLERGIES

1-4 below for women only: (Women note: antibiotics (such as penicillin) may after the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding methods of birth control.)

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You help by paying upon completion of each visit. other arrangements can be made with our office manger depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient

The signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

HIPAA CONSENT FORM
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT & AUTHORIZATION. IN REFUSING WE MAY NOT BE ALLOWED TO PROCESS YOUR INSURNACE CLAIMS.

The undersigned acknowledges receipt of the Notice of Privacy Practices for Kane Dentistry. My signature will also serve as a phi document release should I require treatment or radiographs be sent to another attending provider/facility in the future.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

In signing the HIPPA Patient Acknowledgement form, you acknowledge and authorize that this office may recommend products or services to promote your improved health. We, under HIPPA Rule, provide you this information with your knowledge and consent.