NEW PATIENT DIGITAL FORM

FINANCIAL AGREEMENT AND OFFICE POLICIES

In order to keep our fees as low as possible we have implemented the following policies. Please read the following information carefully to minimize billing and insurance problems.

• The responsible party agrees to pay all attorney fees and court costs associated with collecting payment for services rendered. Collection fees of approximately 50% are added to the account when it is turned over to the agency.
• I grant my permission for you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with a family member.
• I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information either electronically, by facsimile or paper form to my insurance carrier or any related entities that require such information.

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care using only the best material and technology available. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.

ACKNOWLEDGEMENT OF RECEIPT – NOTICE OF PRIVACY PRACTICE

GOOD FAITH EFFORT AND REASON ACKNOWLEDGEMENT WAS NOT OBTAINED (DOCUMENTED BY Radiant Smiles Family and Cosmetic Dentistry)

PERSONAL REPRESENATIVE AUTHORIZATION