I consent and authorize Dr. ANGIE DINH to perform any tests, examinations, and/or dental treatment or alternative treatment, including medications, anesthesia, x-rays, oral and/or physical examinations, and such other specialized dental treatment which is deemed advisable to detect or treat the existing dental and oral conditions.
I hereby give a knowing and voluntary consent for treatment and represent that I have the legal capcity, right, and authority to sign the treatment plans and this informed consent and agreement.
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you read and sign prior to any treatment.
All patients must complete our Information and Insurance form before seeing the doctor.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD/DISCOVER. WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL. WITH CITI HEALTH CARD.
REGARDING YOUR INSURANCE
We may accept assignment of insurance benefits. However, we do require the co-pay of the bill to be paid at time of service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information. Your insurance policy is a contract between you and y our insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will automatically be billed to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable by your insurance policy.
Regarding Insurance Plans (PPO and DMO) where we are a participating provider. All co-pays and deductibles are due at time of treatment. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph.
USUAL AND CUSTOMARY FEES
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates if not a part of a contractual insurance agreement, i.e. PPO Plan.
Adult patients are responsible for full patient payment portion at the time of service.
The adult accompanying a minor or the parents (or guardian of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa/MasterCard, or payment by cash or check at time of service has been verified. Unless cancelled, at least 24 hours in advance, missed appointments at the rate of a normal off
Unless cancelled, at least 24 hours in advance, missed appointments will incur a charge at the rate of a normal office visit of $45. Please help us serve you better by keeping scheduled appointments.
I hereby authorize and consent for Dr. Angie Dinh D.D.S. to release any and all medical, dental, and/or psychological reports or records, including, but not limited to, medical/dental notes, physician narratives, office notes, operative notes, discharge summaries, Doctor's/Dentist's orders, Nurse's notes, lab reports, test results, physical therapy progress notes, patient progress reports, diagnosis, post-operative reports, post-operative diagnosis, pathology reports, x-rays, MRIs, any records reflecting treatment for substance abuse, mental illness, AIDS, HIV virus, alcohol abuse, including any x-rays, diagnostic studies, laboratory slides, clinical abstract, histories, charts, and other information contained therein, any documents and opinions relevant to past, present, or future physical and mental condition, treatment, care or hospitalization, and any other personal health information regarding my medical or dental care as necessary to carry out treatment, obtain payment, and/or conduct other healthcare operations. The release of the matters listed above is being authorized for purposes of obtaining medical/dental treatment, payment for such services and other health care operations.
A copy of this authorizations is agreed by the undersigned to have the same effect and force as an original.
Any person, firm, or entity that releases matters pursuant to this authorization is hereby absolved from any liability.
I FURTHER UNDERTAND THAT I HAVE READ THE NOTICE OF PRIVACY PRACTICES AND UNDERSTAND MY RIGHTS TO MY HEALTH INFORMATION AND MAY REQUEST RESTRICTIONS. I FURTHER UNDERSTAND THAT I MAY REVOKE THIS CONSENT IN THE FUTURE IF I SHOULD SO DESIRE.
THE OFFICE OF DR ANGIE DINH ACCEPTS DENTAL INSURANCE AND FILE CLAIMS AS A COURTESY FOR ALL PATIENTS.
PLEASE READ AND SIGN BELOW
I AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO MY DENTAL CLAIMS TO ALL OF MY INSURANCE CARRIERS.
I AUTHORIZE THE USE OF THIS FORM ON ALL MY INSURANCE SUBMISSIONS.
I UNDERSTAND THAT I AM RESPOSIBLE FOR ALL COSTS OF DENTAL TREATMENT.
I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING ME OBTAIN PAYMENT FROM MY INSURANCE CARRIERS.
I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR.
I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.