Please help us to provide you with the best possible dental care, unique to your individual needs, by answering the following questions, This information is confidential and for our records only
ln order of 1 - 4, (1 being the most, and 4 being the least) what, if anything, prevents you from having dental treatment?
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
IN THE EVENT OF AN EMERGENCY, PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient's records):
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize. that this office may reccomend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Thank you for choosing Dr. Terry Soule as your dental care provider. We are committed to the success of your treatment. The services provided by our office are services you have elected to receive which imply a financial responsibility on your part.
SELF PAY: If you do not have dental insurance, payment is due in full at the time of service.
INSURANCE: We work with many insurance plans, but, please understand that we can only estimate insurance benefits, knowing your insurance benefits is your responsibility. In most instances actual insurance payments vary. Please note that all insurances have a disclaimer stating that information given over the phone or by predetermination is not a guarantee of payment.
COPAYMENTS AND DEDUCTIBLE: All copayments and deductibles must be paid in full on or before the time of service. This arrangement is part of your contract with your insurance company.
NON COVERED SERVICES: Please be aware that some services you receive may not be covered or not considered by your insurance carrier. You are responsible for these services in full.
CLAIM SUBMISSION: As a courtesy to you, we will submit your insurance claims for the services rendered in our office and assist you in any way reasonably we can to help get you claims paid. If your insurance company needs information from youm it is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility, whether insurance pays or not. Your insurance benefit is a contract between you and your insurance company.
PATIENT BILLING: You will be sent up to two statements for your financial responsibility after your insurance has processed claims. After the 2nd notice your account may be forwarded to a Collection Agency. If this occurs, you will be assessed an additional fee of 40% of the amount turned over. Please let us know if you have difficulties in resolving your bill.
PAYMENT POLICY: All balances are due in full on or before the time of our office visit whether or not you have received a statement from our office. We will provide you with a copy of your bill and insurance credits upon request. There is a $35.00 charge for checks returned unpaid by your bank. We accept all major credit cards, debit cards, and offer 3rd party financing through Care Credit and Lending Club.
OFFICE CANCELLATION POLICY: 48 hrs advance notice is required to reschedule or cancel an appointment; in the event that proper notice is not given, Dr. Soule's office reserves the right to charge $45.00 for short notice cancellations. Any broken appointment fees must be paid prior to rescheduling the appointment. Please note that Dr. Soule's office is closed on Fridays, so cancellation notice must be given Monday through Thursday.
We ask all of our patients to sign below to acknowledge that they have read and understand our financial policy. For our patients with insurance, their signature will also authorize their insurance carrier to send payment directly to. Dr. Soule. You may refuse to sign this acknowledgement of our policy. In refusing, we may not be allowed to file claims on your behalf and payment of services rendered will be collected on or before the time of service in the form of cash or accepted credit/debit cards only.
We invite all our patients to visit us on the web at www.souledds.com. Please take a minute to share with us what you like and/or dislike about our website. and how we could improve it. We welcome all suggestions and appreciate your time to help us improve.
Please rate us on a scale from 1 to 5, with 5 being the best, 1 being the worst.