Dental Insurance Information
Policyholder Social Security#:
Identification card present upon encounter:
Eligibility date as indicated on card as:
Is the medical and dental carrier the same?
Other Dental Insurance Information
There are dental conditions that may have medical complications or etiology. To best assist our patients, we find having all information a valuable resource in determining the patient needs and insurance coverage.
Are you allergic to latex?
Have you previously been diagnosed with sleep apnea?
Have you been tested for sleep apnea?
Have you previously been diagnosed with TMJ or TMJD?
Have you received previous treatment TMJ or TMJD?
Have you ever had a reaction to Novacain or Anesthesia?
Martinez & Martinez Family Dental Care
Acknowledgment of Receipt of Notice of Privacy Practices
Purpose: This form is used to obtain acknowledgment of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgment.
,have received a copy of this office’s Notice of Privacy Practices.
For Office Use Only
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but
acknowledgment could not be obtained because (circle one):
Individual refused to sign
Communication barriers prohibited obtaining the acknowledgment
An emergency situation prevented us from obtaining acknowledgment
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication, or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
ASSIGNMENT OF BENEFITS AGREEMENT / FINANCIAL POLICY
Our office will accept an assignment of benefits from your insurance company with the following provisions. It
is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
- Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment. We are not responsible for knowing your individual insurance plan. However, we do our best to obtain whatever information we can regarding your insurance, to better serve you. If you have questions that we cannot answer about your insurance we will refer you to call your insurance provider.
- Our office places composite restorations only. Depending on your particular policy your insurance may not cover this benefit in full.
- We require you to sign this form and/or any other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office.
- We require you to pay the co-payment, and/or estimated outstanding balance which is the amount not covered by your insurance company, at the time we provide service to you. This is an estimated amount, we cannot guarantee an exact amount that will be paid by your insurance company.
- Insurance payments ordinarily are received within 60 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.
- Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time.
- Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.
- If you are a new patient we require you to bring in your most recent radiographs on the day of your examination. These are critical for diagnosis during an examination. Without radiographs your examination is not complete. If you do not have them with you at the time of the examination we will take them. Again, we are not responsible for what your insurance policy is regarding radiographs
- Credit balances under $35.00 will not be returned without a written request after three years.
**Returned checks and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month. Additionally, our office will charge you $50.00 for broken appointments and appointments without 48-hour advance notice.
I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE DOCTOR.
Martinez & Martinez Family Dental Care
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operations?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any
other medications containing bisphosphonates?
Are you on a special diet
Do you use controlled substances?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above?
Past or Present History of (circle all that apply):
Please circle any treatments you are interested in:
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or in the above information. This information will be kept confidential. I am responsible for updating this information if and when there are changes.
We welcome you to our office!! We look forward to getting and keeping your mouth healthy!!!
We are proud members of the AGD (Academy of General Dentistry), ADA (American Dental Association), IOA
(International Association of Orthodontists) and AAFE (American Academy of Facial Esthetics).