Financial Agreement
Thank you for choosing us as your dental care provider. We are committed to ensuring your treatment is successful and meets your satisfaction. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require be reviewed and signed by all patients, and/or guardians of.
Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, our office provides certain services which can include insurance verification and pre-treatment estimates. These services are done at the request of the patient; however, we always encourage you to reach out to your plan directly for any questions regarding network status with our office and to inquire as to what benefits you have available under your specific plan. Some, or perhaps all, of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility regardless if your insurance company pays any portion. If you have any questions regarding the pre-treatment estimate and/or fees for service, it is your responsibility to resolve those prior to treatment in order to minimize any confusion on your behalf.
By signing below, you are acknowledging you understand you are financially responsible for all charges whether or not paid by insurance. If your account becomes delinquent, you agree to reimburse Thomas Olivero, Jr., DDS, PLC the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs and expenses, including reasonable attorney’s fees incurred in such collection efforts.
Patient Name
Date of Birth
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Signature of Parent or Legal Guardian (for minor patients)
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient:
Cancellation and Broken Appointment Policy
A reserved appointment time in any dental office is limited and valuable. Your appointment time is reserved especially for you. If you do not come, not only is your own care delayed, but other patients are not able to be treated during that time. It is extremely important that all patients honor their reserved appointment time(s).
As a courtesy to staff and other patients, our office requires a 24-hour notice for appointment cancellations/reschedules. Appointments that are cancelled/rescheduled with less than 24-hours’ notice may incur a $50 broken appointment fee. In some cases, especially for longer appointment times, you may be asked to give greater notice. There is generally no charge for the first missed appointment but in effort to discourage repetitive broken appointments we may assess a broken appointment fee for the second and each subsequent occurrence.
Every effort is made to contact patients to confirm scheduled appointments. Please understand that this is a courtesy call, text and/or email. It is the patient’s sole responsibility to honor a scheduled appointment. Inability to reach you does not serve as a notice of cancellation.
Patient Name
Date of Birth
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Signature of Parent or Legal Guardian (for minor patients)
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient:
Patient HIPAA Consent Form
Authorization to Disclose Protected Health or Billing information
Patient Name
Date of Birth
I give permission to share my health and/or billing information with the following:
Name
Relationship:
Add another?
Name
Relationship:
Add another?
Name
Relationship:
Add another?
Name
Relationship:
Please read over and initial the following statements:
I understand that anyone in the exam room will hear my private health information.
I give permission to the office of Thomas Olivero, Jr., DDS, PLC to leave a detailed message at the following phone numbers:
I give permission to the office of Thomas Olivero, Jr., DDS, PLC to communicate with me electronically at the email address below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address and that I can withdraw my consent to electronic communications at any time by calling 804-794-2802
Signature of Patient/Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient:
Acknowledgement of Privacy Practices
Copies of the Notice of Privacy Practices are available in the waiting room, as well as
on our website
.
If you would like a copy for to retain for your records, please let the front desk know.
By signing below, I acknowledge that a copy of this office's Notice of Privacy Practices was made available for my review.
You may refuse to sign this acknowledgement.
Patient Name
Date of Birth
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Signature of Parent or Legal Guardian (for minor patients)
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient: