Patient information 25331 ih-10 West, Suite 207 San Antonio, tx 78257



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Leon Springs Dental Center

PATIENT INFORMATION
25331 IH-10 West, Suite 207 San Antonio, TX 78257

210-698-1010 Fax 210-698-1078 info@leonspringsdental.com
WELCOME TO LEON SPRINGS DENTAL CENTER! PLEASE FILL OUT THIS FORM AS COMPLETELY AS POSSIBLE

PATIENT INFORMATION (CONFIDENTIAL) PATIENT #__________________________

NAME___________________________________________________________________BIRTHDATE______________________________

MAILING ADDRESS________________________________________________________________________________________________

CITY_________________________________________STATE__________ZIP_______________ SS#______________________________

HOME PHONE_________________________CELL PHONE_________________________WORK PHONE__________________________

E-MAIL ADDRESS________________________________________ PREFERRED METHOD TO BE CONTACTED___________________

CHECK APPROPRIATE BOX: MINOR SINGLE MARRIED DIVORCED WIDOWED SEPARATED

PATIENT’S EMPLOYER/ SCHOOL____________________________________________________ FULL TIME PART TIME

SPOUSE/PARENT’S NAME________________________________________________PHONE___________________________________

EMERGENCY CONTACT__________________________________________________PHONE___________________________________

WHO MAY WE THANK FOR REFERRING YOU?_________________________________________________________________________

PREVIOUS DENTIST NAME/NUMBER_______________________________________________LAST VISIT________________________

PRIMARY CARE PHYSICIAN________________________________PHONE__________________LAST PHYSICAL__________________
RESPONSIBLE PARTY

NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT____­­­­­­­____________________________________________________________

RELATIONSHIP TO PATIENT_____________________________________HOME PHONE______________________________________

ADDRESS_______________________________________________________________________________________________________

DRIVER’S LICENSE #________________________BIRTHDATE________________________SS#________________________________

EMPLOYER___________________________________________________WORK PHONE______________________________________

IS THE RESPONSIBLE PARTY CURRENTLY A PATIENT WITH DR. CAROLYN WALKER? YES NO
DENTAL INSURANCE INFORMATION

NAME OF INSURED__________________________________________________RELATIONSHIP TO PATIENT____________________

BIRTHDATE___________________________SS#_______________________________DATE EMPLOYED_________________________

NAME OF EMPLOYER_________________________________________________WORK PHONE________________________________

EMPLOYER ADDRESS___________________________________________CITY_________________STATE_________ZIP___________

INSURANCE COMPANY___________________________________________________________PHONE___________________________ INSURANCE CO. ADDRESS_______________________________________CITY_________________STATE________ZIP____________

POLICY/ID #______________________________________________GROUP #________________________________________________
DO YOU HAVE ANY ADDITIONAL DENTAL INSURANCE?  YES  NO

Leon Springs Dental Center
OFFICE POLICY

We feel the best thing about our style of dentistry is our commitment to quality. If you’ve been with our practice a while, you already know our attention to detail. Fine materials are second nature to us. Everyone’s financial situation is different, and good dentistry will not count for much if it is beyond your means.


We work with most dental insurers. We are a contracted provider with United Concordia, Delta Dental Premiere, Humana and Cigna PPO. However, we do accept all PPO plans and we will go over any questions that you may have. We will help you get the most benefit out of your particular policy. We will file your claims for you and answer any questions we can for you. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less than anticipated. We do ask that you pay your portion at each visit.
We accept Visa, Discover and MasterCard credit cards. We also accept Care Credit and Citi Healthcard if you qualify. We will work with you to devise a method of payment amendable to us both. Ask us about our available payment plan options.
Our doctors and hygienists strive to render excellent dental care to you and the rest of our patients and we understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for 48 hours advance notice; this allows for other patients an opportunity to be scheduled. Although we have always had a cancellation policy, circumstances have caused us to enforce a policy of charging $35 for no-show appointments, and those appointments not cancelled within 48 hours.

If you share our belief in quality dentistry – the best dentistry we can possibly achieve – then we will find a way to make it part of your life.


Sincerely,
Leon Springs Dental Center

Patient Signature________________________________________Date__________________________



Leon Springs Dental Center
Acknowledgement of Receipt of Notice of Privacy Practices
*You may refuse to sign this acknowledgement*

I, ___________________________________________________________________________,

Patient’s Name

Have received a copy of Leon Springs Dental Center’s Notice of Privacy Practices.


______________________________________________________________________________

Name (Print)


______________________________________________________________________________

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):

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Leon Springs Dental Center

F

INANCIAL RESPONSIBILITY AND DENTAL INSURANCE

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount that insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file all insurance electronically so your insurance company will receive each claim within days of the treatment. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 60 days a finance charge of 1.5% will be added to your account each month until paid. We will be glad to send a refund to you once insurance has paid us.
Please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment; we at no time guarantee what your insurance will or will not do with each claim. We also cannot be responsible for any errors in filling your insurance; once again we file claims as a courtesy to you.

Fact 1 – NO INSURANCE PAYS 100% OF ALL PROCEDURES


Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee.

Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.



Fact 2 – BENEFITS ARE NOT DETERMINED BY OUR OFFICE


You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company.
A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate.
Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.
Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.

DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED


When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your dental plan pays only at 50% then the insurance benefits will also be significantly less.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.
I HAVE READ THE ABOVE FINANCIAL RESPONSIBILITY STATEMENT AND UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO LEON SPRINGS DENTAL CENTER / DR CAROLYN WALKER FOR ALL CARE AND SERVICES PROVIDED TO ME.

PATIENT SIGNATURE______________________________________________ DATE__________________


Leon Springs Dental Center
SIGNATURE RELEASE STATEMENT
YOUR SIGNATURE IS NECESSARY FOR US TO:


  1. PROCESS ALL INSURANCE CLAIMS

  2. ENSURE PAYMENT FOR SERVICES PROVIDED

  3. RELEASE MEDICAL INFORMATION TO INSURANCE COMPANIES NEEDED FOR THE PROCESSING OF YOUR CLAIMS

  4. RELEASE INFORMATION TO OTHER MEDICAL AND DENTAL PROVIDERS, INCLUDING LABORATORIES, WHEN NECESSARY, FOR YOUR TREATMENT

I hereby authorize the release of all medical information necessary to process my claims and I authorize release of this same information, when necessary, to other providers rendering medical/dental care, as well as to labs that need my information to make a diagnosis or fabricate an appliance necessary for my treatment.
I assign all medical and surgical benefits, including major medical benefits to which I am entitled, to Dr. Carolyn Walker / Leon Springs Dental Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignm01.ent is to be considered as valid as the original.

Patient Signature _________________________________________________


Patient Full Name (printed) _________________________________________
Parent Signature (if minor) _________________________________________
Witness ________________________________________________________
Date Signed _____________________________________________________


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