Patient Information

Name*

Soc.Sec. #

Address

Email*

City

State

Zip

SexnoneMaleFemale

Birthdate

Martial StatusnoneSingleMarriedDivorcedOther

Home Phone*

Mobile Phone

Patient employed by

Occupation

Business Address

Business Phone

Whom may we thank for referring you?

In case of emergency who should be notified?

Phone

Primary Insurance

Person Responsible for the Account

Relation to Patient

Birth date

S.S#

Address (if different from patient)

Phone

City

State

Zip

Business Address

Business Phone

Insurance Company

Group #

I.D. #

Subscriber S.S. #

Assignment and Release

I, the undersigned certify that I (or my dependant) have insurance coverage with above mentioned insurance company and assign directly to Dr.Julio A. Rodriguez all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. 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 insurance submissions.

Responsible Party Signature

Relationship to patient

Date

Patient Acknowledgement of Receipt of the Notice of Privacy Practices

I acknowledge that i was provided with a copy of the Notices of privacy Practices, describing how my health information may be used or disclosed under the federal law. I hereby consent to the use and disclosure of my health information for the purpose and the activities under the federal privacy law. Iam aware that the Notice may be changed at any time I may obtain a revised copy by calling the offices

Date :

Patient's Name :
Signature (if minor Parent or Guardian)

Patient's Legal Representative (if applicable)
Signature of Legal Representative

Dental Arts of Sunset Office Policies 2017

All fees will be explained to patient along with the proposed treatment plan before any services are commenced. Fees are to be paid in full at the time of service.
Initial
Sometimes during treatment the plan may have to be modified at the Doctors discretion to account for any complications that may have been unforeseeable. Procedures may have to be added or omitted. No new procedures will be commenced without disclosing any additional fees to patient.
Initial
Accounts 30 days past due will incur finance charge of 1.5% per month. Accounts 60 days past due will be turned over to either collection agency or attorney.
Initial
In the event that collection or court proceedings are necessary to collect sums due and owing to us, the patient agrees to be fully responsible for the payment of all attorneys’ fees and costs in connection with the proceedings (due to returned checks or otherwise).
Initial
Your appointment time is RESERVED exclusively for YOU. We NEVER double book patients. This allows us to run on time and more importantly it allows YOU to run on time without annoying waits. In order to accomplish this we cannot tolerate broken appointments. If you have an appointment with us and your plans change we require 48 hours advance notice, or as soon as possible, in case of an emergency so your appointment will not be considered “BROKEN”. Any patient who breaks and appointment will be required to give a $50/hour deposit in exchange for a future appointment. Deposit will be forfeited in the event the appointment is broken again.
Initial
Patients with insurance. We will be happy to file on your behalf. We will also try to estimate what they may cover. Our estimates are based on a telephone conversation with an operator at your insurance company. This is NOT A GUARANTEE OF BENEFITS and we cannot be responsible for the terms/limitations and exclusion of your particular plan. We encourage you to become familiar with the fine print of your plan. Patients will be required to pay in full any claims not paid by the insurance carrier within 30 days and any remaining balance if the insurance pays less than what was estimated.
Initial
This agreement, when signed by both parties, is a legal, binding contract and supersedes all other agreements, oral, written, past or present.
Initial

Patient or Guardian :

Date :

Office Representative :

Date :

Payment Options

Cash
Credit Card- Visa, Master Card, American Express, Discover Card
Personal Check: Processed through TeleCheck
DEBIT/ATM Card
CareCredit or Lending Club: Third party financing Company

I have Read and understand the payment options of this office.

Patient or Guardian Signature

Date :

About Us