About You. Today s Date: Married Single Partnered Divorced Separated Widowed. Home Address: CITY STATE ZIP. Employer s Address: CITY STATE ZIP

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1 Welcome Please fill out this form completely, it is important to your care. & ROBBINS TOMMY L. OWENS, D.D.S. MARION W. STAFFORD, D.M.D Peachtree Rd. NW - Suite 600 Atlanta, GA Today s Date: Married Single Partnered Divorced Separated Widowed Name: Prefers to be called: LAST FIRST MI About You M F Birthdate: Age: Soc. Sec. #: Driver s Lic. #: Home Address: Home #: ( ) Cell #: ( ) Work #: ( ) Address: Whom may we thank for referring you? When are the best times to reach you? Other family members seen by us: Employer: How long there? Occupation: General Doctor: Previous or Present (Please circle) Date of last visit: In the event of an emergency, whom should we contact? (Other than spouse) His/Her Name: Relation: Wk #: ( ) Hm #: ( ) Address: SpouSe InformAtIon His/Her Name: Birthdate: SS #: Employer: Wk #: ( ) DL #: Person Responsible for Account, if other than yourself Name: Relation: SS #: Employer: Wk #: ( ) DL #: Hm #: ( ) Billing Address: Primary Dental Insurance DentAl InSurAnce InformAtIon Insurance Co. Name: Ins. Co. Ph #: ( ) Group # (Plan, Local or Policy #): Insurance Co. Address: Insured s Name: Relation: Insured s Birthdate: SS #: Insured s Employer: Secondary Dental Insurance Insurance Co. Name: Ins. Co. Ph #: ( ) Group # (Plan, Local or Policy #): Insurance Co. Address: Insured s Name: Relation: Insured s Birthdate: SS #: Insured s Employer:

2 Our mission is to serve our patients with the finest dental care. We will constantly strive to achieve personal and professional goals while providing quality service for our patients. We will provide this service with honesty and empathy. We are committed to being an enthusiastic team, to exceeding our patients expectations, and to promoting their life-long dental health. In order to meet the goals of our stated mission, it has thus been necessary to establish the following guidelines for our practice. DentAl InSurAnce benefits As a courtesy to our patients, we are happy to file for expected dental benefits. However, we are no longer able to keep balances on accounts that are related to outstanding claims past 90 days. We will only be able to send one appeal for any denied benefits. We ask our patients to take responsibility for their benefits policies and for making sure such expected benefits are indeed paid. Any amount not expected to be paid by the insurance policy is to be paid by the patient at the time of service. Patients are also to pay at the time of service if the insurance policy only allows payment of benefits to the policy member. financial ArrAnGementS Upon approval, we provide in-house financial arrangements for up to three months payments. If it is necessary to extend payments over a longer period of time, then treatment should be phased or patient should apply for CareCredit. professional courtesies For treatment plans of $1000 or more, a 5% courtesy discount is given when payment is made via cash or check, prior to the treatment s start. If payment is made via credit card, a 3% courtesy discount is given. forms of payment Cash, check, MasterCard, Visa, American Express and Discover credit cards are accepted. CareCredit is an alternative form of payment for patients who complete the application and are approved. cancellation/no SHoW policy A courtesy of 48 hours notice is required for any changes in the schedule. If you must change or cancel an appointment with less than the above required time there will be a possible non-refundable charge of $50.00 charged to your account. This amount must be paid in order to allow the rescheduling of any appointment. AutHorIZAtIonS 1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name and patient) s dental needs. 2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. 3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for complete recital of any complications. 4. I agree to be responsible for payment of all services rendered on my behalf or dependents. I understand that payment is due at the time of service unless other arrangements have been made. If your account becomes thirty (30) days past due, I understand that a 1.5% interest (18% APR) will accrue to my account. If you do not pay your account it will be placed with a third party law firm debt collector. You will then be liable for the principal, interest and attorney s fees of fifteen (15) percent of the principal and interest owing, court costs and all costs of collection if collected by or through an attorney at law who is not our salaried employee. If required, I also understand our office or agents may obtain and review your credit report. I consent that the phone number provided are valid and that our office or agents calling you at the phone numbers provided. I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need. My method of payment will be. SIGNATURE DATE I certify that I am covered by Insurance Co. and I assign directly to Dr. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. PAYMENT IS DUE AT TIME OF SERVICE. SIGNATURE DATE

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5 ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES *You May Refuse To Sign This Acknowledgement I,, have received a copy of this office s Notice of Privacy Practices. Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice Of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify) Office: (404) Peachtree Road, NW Suite 600 Atlanta, GA 30309