Responsible Party: (if different from above)
FINANCIAL AGREEMENT: Payment is due at time of service
Financial assistance is available, upon credit approval.
As a courtesy to you, we will submit all charges to the insurance company. Insurance is designated to cover a portion of the customary fee. Co-payments are collected at time of visit. (Please see our insurance policies.)
BALANCES LEFT ON ACCOUNT FOR OVER 60 DAYS: All parties will be responsible for the cost of collection, which may include but is not limited to any and all collection and legal fees.
Returned checks: There will be a $25.00 fee.
CANCELLATION AND FAILURE TO ARRIVE:
We understand that circumstances do arise that can keep you from a dental appointment. Please, have the courtesy to give the office 48 hours notice. Please understand that we have reserved the doctors time for you and we will try to contact you at all phone numbers listed to confirm your appointment.
To reserve a treatment appointment with one of our general dentists there will be a deposit of $200.00 required at time of scheduling which is applied towards any dental co-payment.
There will be a $75.00 charge for all Hygiene and General Dentist appointments missed or cancelled without 48 hours notice.
To reserve a treatment appointment with one of our Specialists on Staff (perio or endo), there will be a deposit of $200.00 required at time of scheduling which is applied towards any dental co-payment. 72 hours notice needed for cancellation.
There will be a $200.00 charge for all specialist appointments missed or cancelled without 72 hours notice.
X-RAYS: Digital x-rays are the property of CitiDental. If you wish to have your x-rays emailed, a notice of 24 hours is necessary.
Privacy Act: I give CitiDental permission to send reminder postcards to me through U.S. Postal Service, and to leave messages via answering machine, voicemail, e-mail, cell phone, or other family members.
By signing below, I understand the above listed policies, and assume responsibility for all services rendered.
In order to submit claims accurately, the following are needed:
1. We need all necessary information on the policy holder.
2. Information does need to be verified by the insurance company.
Information provided by the insurance company IS NOT A GUARANTEE OF BENEFITS, only an estimation. Please review your policy book so there are no misunderstandings. If you do not have a policy book, contact your human resource office.
You, the patient, are responsible for your own policy, we are third party billing only, and given minimal information by your insurance company.
You are responsible for all co-pays at time of service, and any balance that may occur after the insurance has paid. We do send dental pretreatment estimates to your insurance if treatment is diagnosed and discussed. This is done to have approval on file if treatment is rendered. It is NOT submitted for reimbursement until actual services are performed.
To give you the best estimate possible with the information given to us by your insurance company. Until the insurance company receives the actual CLAIM, it remains an ESTIMATE and not a GUARANTEE. TREATMENT PLANS AVAILABLE.
By signing below,
I authorize direct payment of the insurance benefits to CitiDental and its’ associate doctors, for treatment rendered to me and/or my child/children.
I have read and understand the above policies.
WHAT PERSONAL INFORMATION DO WE GATHER ABOUT YOU?
Your contact information, such as your email, home address, ZIP code, phone number and email. Such items are collected when you sign up for our contests or promotions, or use our online appointment scheduling process.
Your name, date of birth, insurance information, appointment date and time and family member information. Such items are collected when you use our online appointment scheduling process.
Your public information, such as comments or reviews that you post on our site. We also collect requests or questions that you publicly post.
Your demographic information, such as your postcode, preferences and interests.
Other information, such as your location, your IP address, the browser/device/hardware you are using, your GPS location and what pages you visit on our site. Such items are collected when you visit our website, affiliated websites, or any other digital property associated with us .
HOW DO WE USE YOUR INFORMATION?
To keep an internal record for our reporting and analysis purposes.
To provide you with relevant content, materials, offers, programs and to administer your participation in our contests or sweepstakes.
To respond to your requests or questions that you may provide via our social sites.
To improve our sites, products, services and other marketing purposes.
To protect the office, other patients and our assets and sites and for other security measures.
To remain in communication with you with any products or services you requested.
To schedule an appointment for you, and contact you via mobile phone text/SMS or e-mail to confirm your appointment.
From time to time, we may also use your information to contact you for market research purposes. We may contact you by email, phone or mail.
To target ads to you based on your past online activity.
We will never sell your information.
I have received a copy of this office's Notice of Privacy Practices.