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Version 01.02.2014 Serang Dental Associates, LLC Family & Cosmetic Dentistry Serang Dental Associates, LLC OFFICE POLICIES OFFICE POLICIES Welcome to Serang Dental Associates! It is our goal to serve your needs as best we can while maintaining a professional environment you can enjoy and feel safe in. We would like to use this form to inform you of some of the nuances, risks, limitations and challenges of performing dentistry in the office setting. Please ask our doctors if you have questions! Privacy Policy: Please read our Privacy Policy and understand how we are planning to protect your personal health and financial information. We ask that you list any specific requests on how to handle your personal health and financial information under the special requests of this form. I have read the attached Privacy form. ___________________ Name of Minor, if minor X___________________ Signature Reasons unable to obtain signature: ___________________________________ X________________ Date _____________(staff initial) All patients are entitled to a copy of their dental records. We are happy to send them to you or a dentist by your request after having a signed release only by you. We may request an administrative fee of $20.00 due prior to records being sent. Use of local Anesthesia and dental materials Policy: We routinely use local anesthesia and FDA approved dental materials to help achieve a comfortable experience as well as maintain high quality dental care at our office. We would like to inform you of some risks associated with these items. Most risks of local anesthesia are related to the position of the nerves and blood vessels under the tissue at the site of the injections, which cannot be determined prior to administration of the anesthetic agent. Complications rarely occur but they may include (but not limited to) loss of or disturbed nerve sensation of the tongue, lip, cheek and chin on the side of the injection. This is usually temporary and normal sensation eventually returns within a few days. In rare cases this may last longer and may become permanent. There also may be soreness, pain, swelling or bleeding at the site of injection, and increased heart rate leading to fainting spells in rare cases. In addition, anesthesia or other dental materials may result in an allergic or toxicity reactions and trouble breathing which made lead to life threatening situations. I understand no guarantee or assurances can be given regarding results that may be obtained. I further understand that individual reactions to treatment cannot be predicted and any unusual reactions should be reported to the office or local hospital emergency room soon as they are recognized. There are alternatives to local anesthesia that I can choose. I will always report any change in health status or medications I take to the office. I give my permission to use local anesthesia. ___________________ Name of Minor, if minor X___________________ Signature X________________ Date Amalgam Fillings information Policy: Local legislation requires the office to present information regarding the mercury content in amalgam fillings. Insurance companies also require us to offer amalgam fillings for particular covered treatment options and so we do offer amalgam fillings as a form a treatment. I have read the attached Philadelphia Amalgam form. ___________________ Name of minor, if minor X___________________ Signature X________________ Date Note: Some insurance companies will downgrade fees of composite/resin fillings on back teeth (posterior teeth) to an amalgam fee (amalgam has a lesser fee). This could lead to a drop in percent coverage of the filling if you choose a white filling. For these reasons we advise that you check with your insurance company regarding these nuances of your coverage before appointments that involve more than a cleaning as any estimations by our staff cannot guarantee coverage. 8016 Ridge Ave., Philadelphia, PA, 19128 Phone: (215) 482-8600 Fax; (215) 482- 8600 www.serangdentalassociates.com 1 Version 01.02.2014 Serang Dental Associates, LLC Family & Cosmetic Dentistry Serang Dental Associates, LLC Dental Insurance Policy: OFFICE POLICIES OFFICE POLICIES PPO’s type plans are the only type of insurances we participate with, but we do not participate with all PPO’s. Please confirm with your insurance that we are in network, out of network or non-participating so you will know how to apply your explanation of benefits. There appears to be hundreds of dental insurances and numerous versions of each one and we are unable to guarantee coverage or network status at any time. Our office staff can only give recommendations or estimations based on our experience but the responsibility and liability for services rendered will be with the patient. We do not participate with any Medicaid (Keystone, Health Partners) or DMO’s or Blue Cross Blue Shield plans (we are unable to process claims for these insurances as well). If patients receive payments from the insurance directly we recommend you call our office to report it as it may be an error and you may be liable to the office for that amount and more. If you prefer to have payments sent to you directly from insurance for services rendered, payment will then be due at the time of the appointment (UCR Fees may be used if network status is not confirmed). Estimated of benefits, pre-authorizations, or pre-estimates are not a guarantee of coverage and you will be liable for the usual customary doctor fee schedule (based on NDA fee scheudule: 70 percentile) until claims confirm your coverage and our network status. It is the office policy that all dental billings not covered by insurance are subject to the doctor fee schedule if not covered by insurance (includes downgraded resin composite fee to amalgam, porcelain downgrade to metal crowns, etc.) even if in-network. We do not guarantee we know which procedures will be downgraded or not covered by your insurance and only give estimations based on what we have seen. We can only offer what we feel are best options based on our experience and standards of care. Financial Responsibility policy: All payments, open balances, copays and coinsurances are due at the time services are rendered. Our office accepts all major credit cards and cash payments. We will accept payments from your insurance carrier and bill whatever remaining balance your insurance did not cover. We will send you a check payment if your copay was an overpayment. Doctors may dictate alternate payment options with office staff and patients by applying an alert to the ledger for special circumstances. However, we do reserve the right to override these alternate plans and request that payments be due at time of services at all times. Patient and doctor must have signed agreement if alternate financial options are agreed upon. All payments billed by statement are due 30 days after being sent. The office reserves the right to add $50 late fee after 60 days past due. After 90 days, past due the doctor will reserve right to send accounts to a collection agency which may be subject to court costs, collection cost of 30% and reasonable attorney fees. I understand and agree to the financial responsibility policy stated above. Cancellation Policy: ___________________ Name of Minor, if minor X___________________ Signature X________________ Date We ask that patients who want to be in good standing with the office to give 48-hour notice for cancellations. We reserve the right to issue $50.00 cancellation fee if notice is 24-hrs or less (we may request documentation if emergency cancellation prior to waiving this fee in the 24-hr period). Practice Dismissal Policy: We strive to operate this office in an efficient, safe and fair manner. If polices of the office are not honored by the patient we reserve the right to dismiss the patient from our care and ask the patient to complete and continue their care at another dental office. Additional behavior that may warrant this would be any deliberate falsifying of information, sexual harassment, inappropriate or hostile language, threats of violence, and any other inappropriate behavior deemed inappropriate to the dental office setting. We strive for equal treatment to people of all disabilities, race, religion, economic status and sexual orientation. 8016 Ridge Ave., Philadelphia, PA, 19128 Phone: (215) 482-8600 Fax; (215) 482- 8600 www.serangdentalassociates.com 2 Version 01.02.2014 Serang Dental Associates, LLC Family & Cosmetic Dentistry Serang Dental Associates, LLC Specialist referrals policy: OFFICE POLICIES OFFICE POLICIES As a general dentist we only provide dental services limited to general dentistry. We are happy to refer patients to specialists for other services but patients are required to pay all fees associated with visits to specialist, to the specialist, unless otherwise agreed upon in writing prior to the referral. Specialists may be utilized for consultations, second opinions, to address complications of treatment, or for treatment deemed too difficult for the general dental office setting. By signing this I have read the version 01.02.14 and have been adequately informed of them. Addendums to this policy may be offered each year to inform patients of any changes. Thank you and we look forward to serving your dental needs! Privacy Policy Local Anesthesia Policy Amalgam information Policy Dental Insurance Policy Payment Policy Cancellation Policy Practice Dismissal Policy Specialist referrals Policy ____________________ Name of Minor, if minor X_______________________ Signature X________________ Date Version 01.02.2014 Version Specific requests: X___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Updated versions of office policies can be reviewed on our website at www.serangdentalassociates.com 8016 Ridge Ave., Philadelphia, PA, 19128 Phone: (215) 482-8600 Fax; (215) 482- 8600 www.serangdentalassociates.com 3