Fill - Free fillable Jeff Berlin Patient Information Form Sep-06 PDF form

Office Policies and Financial Agreement:

Please read carefully and feel free to ask any questions you may have before signing in agreement below.

Your appointment will begin with a consultation. This includes an exam and any necessary x-rays. For

your consultation today you will be responsible for $195-$295. We will make every effort to acquire and use any x-

rays you have had recently, but in order to ensure the diagnostic quality of the images and in the interest of

keeping our appointments running on time, it is often necessary to take our own x-ray. X-rays are critically

necessary to your consultation and diagnosis. Any x-rays will be completed at no additional cost as part of your

consultation. We want to make sure you understand your treatment, your options and your financial

responsibility before you agree to proceed with treatment. Following the exam, all findings and treatment

recommendations will be clearly presented and the costs to proceed with these recommendations will be

discussed with you before treatment begins. The cost of a root canal can range from $1500-$2500 depending on

the location of the tooth and its severity. I _________ understand that once I have agreed to proceed with

treatment I am responsible for all fees as presented to me for this service.

In an effort to do our part for the environment we have eliminated paper statements. As such, payment

is expected in full at the time services are rendered. We gladly accept Cash, Visa, MasterCard, Discover and

American Express, as well as flex spending. We have also partnered with Care Credit to offer 6 month interest free

or 24 month fixed interest financing options (upon approval).

Patients with dental insurance please read the following information about your benefits and their effect on

your financial responsibility.

We are happy to accept all PPO dental insurances and we are in-network with some. We do not accept

HMO or medical insurances. Your insurance is a contract between you and your insurance company. As a courtesy

the financial representatives of Advanced Endodontics will help you understand how your benefits may be applied

toward your treatment and will submit claims on your behalf to your insurance company. As part of this courtesy,

Advanced Endodontics will contact your insurance company and try to estimate what the insurance will pay and

the patient portion of payment expected for your services. I __________________ understand that my presented

co-pay is only an estimate and not a guarantee of any payment or reimbursement from my insurance company.

I understand that I am fully responsible for any payments due to Advanced Endodontics that are denied by my

insurance. As such, if there is still a balance due after your insurance has processed your claims you will be

notified of your balance and it will be charged to your card on upon receipt of final insurance payment or denial.

Likewise if the insurance pays more than expected and you are due a refund, the credit will be refunded to you

upon receipt of final insurance payment.

I have read the above and understand my full financial responsibility to Dr. Berlin for any and all services

rendered to me from this date forward regardless of my insurance coverage.

Print Full Name: ______________________ Patient Signature: _____________________ Date: ______________

Preferred Method of Payment on File: CASH VISA MASTERCARD AMEX CARECREDIT

Name of Cardholder: Last 4 of card number: Expiration: CVC Billing Zip

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Patient HIPAA Consent Form

You have certain rights to privacy regarding your protected health information under the Health

Insurance Portability Act of 1996 (HIPAA). By signing this consent, you authorize this office

(Jeff Berlin, DDS, MS and Associates) to use and disclose your protected health information to

carry out the following:

 Treatment and reporting treatment notes to your Doctors (including direct or indirect

treatment by other health and dental care providers involved in your treatment)

 Obtaining payment from third party payers (e.g. your insurance company)

 The day-to-day healthcare operations of our practice (e.g. contact with you and

authorized members of your care)

Print Patient Name______________________________________

I understand that I have the right to request restrictions on how my protected health

information is used and disclosed to carry out treatment, payment and health care operations. I

have also been informed that I may request and secure a copy of your Notice of Privacy

Practices, which contains a more complete description of the uses and disclosures of my

protected health information and my rights under HIPAA. I understand that you reserve the

right to change the terms of this notice from time to time and that I may contact you at any

time to obtain the most current copy of this notice.

I understand that I may revoke this consent, in writing, at any time. However, any use or

disclosure that occurred prior to the date that I revoke this notice is not affected.

Signature______________________________________ Date signed _____________________

Fill Online, Printable, Fillable, Blank Jeff Berlin Patient Information Form Sep-06 Form

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Fillable Jeff Berlin Patient Information Form Sep-06

Fill Online, Printable, Fillable, Blank Jeff Berlin Patient Information Form Sep-06 Form

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