(If someone other than the patient)
Primary Insurance Information
Secondary Insurance Information
Our primary goal is patient safety, and although our dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.
Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.
Do you have, or have had, any of the following?
Welcome to our practice. We appreciate your selection of our office to serve your dental health needs. Our goal is to provide the very best possible dental and periodontal care for our patients.
Please read the following statements. The patient or legal guardian must agree and sign.
The undersigned hereby authorizes the doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the patient's dental needs. I further authorize and consent that the doctor may consult with my physician or other health care providers regarding my periodontal treatment. I also authorize the doctor to perform any form of treatment, medication, and/or therapy that may be indicated. I understand that the use of anesthetic agents and certain treatments embody some risk. In good faith, the doctor will present these risks and alternatives to proposed treatment and my questions will have been answered in order to proceed.
Regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time.
Part of our commitment to patient care is to provide you with information about your dental needs and treatment, including the estimated costs of your quality care. Our fees are individually based on the time, severity, and difficulty of your specialty treatment. Payment not covered by your insurance is expected at the time of service. We accept cash, check, ATM, and credit card payments. A $25.00 fee is charged an all returned checks. A 1.5% service charge will be assessed on all accounts not settled within 90 days of service.
I understand that I am responsible for any payment due for services that I have received. In addition to the portion of the services not covered by my insurance carrier, I am responsible for any outstanding balance after the insurance carrier has been estimated and/or billed. I also understand that payment not covered by my insurance is expected at the time of service. If the Clarke V. Filippi, DDS, Inc. Periodontal Practice is subsequently paid by the insurance carrier I will be reimbursed.
Finally, I understand that the Clarke V. Filippi, DDS, Inc. Periodontal Practice reserves a specific time for me on their appointment schedule and that not confirming an appointment, cancelling an appointment without 24-hour notice or not showing to an appointment does not allow time for that vacancy to be filled. Therefore, I am hereby notified that this office reserves the right to charge for and cancel unconfirmed, missed appointments or those cancelled without 24-hour notice.
Acknowledgement Of Receipt Of Notice Of Privacy Practices
*You May Refuse to Sign This Acknowledgment*
I have received a copy of this office's Notice of Privacy Practices.
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We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: