Financial/Office Policy
We value our relationship with you. Creating a mutual understanding of our financial policy will ensure the ongoing success in our partnership. Please familiarize yourself with the information below and speak with a staff member if you have any questions.
PATIENT INFORMATION
Patient's Name*
First Name Last Name
Patient's date of birth*
Month Day Year
Date
FINANCIAL/INSURANCE POLICY
Payment Policy
Full payment is due at time of service. We accept cash, personal checks, Visa, MasterCard, American Express, Discover, and have payment plans available through CareCredit. If you have insurance, we will collect applicable copays/deductibles.
Returned Checks Policy
Returned checks are subject to a $35 return check fee.
Dental Benefits
You are responsible for understanding your dental benefits and have ultimate financial responsibility for your account, regardless of whether your dental insurance benefit covers part of your treatment. We are happy to provide you with an estimate of what we believe your dental benefits will cover based on information provided to us by your benefit provider.
Dental services that require laboratory fabrication (e.g. athletic/night guards, pontics, retainers) require full payment at time of impression.
Retail Products, Sonicare toothbrushes, Clinpro Toothpaste & whitening products are non-returnable and must be paid in full at time of purchase.
Past Due Accounts
Accounts more than 90 days past due may be transferred to a collection agency. Patients shall be responsible for all costs incurred for the collection of past due balances. This includes collection agency fees, attorney fees, and any other costs involved in litigation.
Financial policy agreement*
I accept and understand the terms of the financial policy
INSURANCE ASSIGNMENT OF BENEFITS AUTHORIZATION*
I authorize my insurance to pay my benefits directly to the dentist/office for all services rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I acknowledge that I am financially responsible for all charges, whether or not paid by insurance. This will serve as my electronic signature for Assignment of Benefit. I do not authorize assignment of benefits and I will pay full fees at the time of service. I understand that the dentist office will print an insurance form for me to submit and my insurance will reimburse me directly.
CONSENT FOR ELECTRONIC COMMUNICATIONS
To serve you better, Southwest Pediatric Dentistry and Orthodontics, PC (SWPDO) sends automated SMS Text Message and email appointment reminders. These reminders do not contain Protected Health Information (PHI). At your request, we can also communicate with you for scheduling appointments, providing PHI to you or an authorized recipient, or for other reasons that may contain your PHI.
By selecting below, I authorize SWPDO to contact me by the means selected to the contact information. By authorizing, I acknowledge that I have read and understand the following:
- Message/data rates may apply to messages sent to my cell phone.
- I may opt-out of receiving these communications at any time by calling SWPDO at (303) 978-1104 or replying to the text or email as indicated in the message.
- As a general practice SWPDO does not send PHI by email, unless requested by the patient or authorized person to be sent by email.
- If I request anything containing my PHI to be sent electronically, I understand that PHI could possibly be read by unintended parties such as but not limited to the following: people that have access to my devices that receive my email, my email provider, my company (if using company email), stored on servers that are not HIPAA security compliant, etc.
Consent for SMS Text Messaging and Email*
YES NO, I opt-out of electronic reminders and communication
FORM COMPLETION
Signature of Patient, Parent or Guardian*
Clear
Date*
Month Day Year
Date
IF PATIENT IS A MINOR
FORM SIGNED BY RELATIONSHIP TO PATIENT
Should be Empty:

Financial/Office Policy

PATIENT INFORMATION

FINANCIAL/INSURANCE POLICY

CONSENT FOR ELECTRONIC COMMUNICATIONS

FORM COMPLETION