Consent of Information
We are committed to protecting the privacy of our patient's personal information by utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when required by law.
We collect information from our patients such as names, home and work addresses, home, work and cell phone numbers, and email addresses (collectively referred to as contact information). Contact information is collected and used for the following purposes:
- To open and update patient files
- To contact patients about their estimates
- To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
- To process claims for payments or reimbursement from third-party health benefit providers and insurance companies
- To send reminders to patients concerning the need for further dental examination or treatment
- To send patient information and material about our dental practice
Contact information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients behalf.
Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical conditions, and dental treatments (collectively referred to as "medical information"). Patient's medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients medical information is disclosed:
- To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf
- To other dentist or dental specialists where we are seeking a second opinion and the patient has consented to us obtaining a second opinion
- To other healthcare professionals such as physicians, if the patient, with their consent, has been referred by us to the other healthcare professional for either a second opinion or treatment
If we are ever considering selling all or part of the dental practice, qualified potential purchasers may be granted access to patient information as part of the due diligence process in order to verify information important to the potential sale. If this occurs, we will take steps necessary to ensure that the prospective purchaser safeguards all information.
Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regular activity in the public interest.
I consent to the collection, use and disclosure of my personal information and medical information as set out on this form.
Forms of payment and balances due:
In order to facilitate access to the very best dental care possible, you may choose from any of the following payment options (combinations are also acceptable): Cash, Debit, Visa, MasterCard, American Express, money order, and/or a Previously Arranged payment plan.
It is our pleasure to assist you in maximizing your insurance benefit by completing your claim forms. If your carrier is up-to-date, the claims will be transmitted electronically the same day. If we receive an immediate response from your insurance company, we will know the total balance owing bracket if any bracket and collect payment of the completion of your appointment. If we do not receive an immediate response from your insurance company at the conclusion of your appointment, we will collect a 30% pre-payment (which is an estimate of your portion after insurance has been paid).
Some policies will not pay us directly. If this is the case, a cost estimate for the treatment done is given to you. Please understand that this is only an estimate, and is based upon the information available to us. Your insurance claim will be sent by mail and we will then forward the remaining balance to you once we have received payment from the insurance company. It is your responsibility to inform us if there have been any changes to your policy(s) since your last visit.
The range of benefits depends solely on what you or your employer have purchased. Some plans cover as little as 30% or as much as 100% of dental services, with most falling in the 40 to 80% range.
Some plans base the amount they pay for procedures on a schedule of fees arbitrarily determined by insurance companies. For this reason you may receive a lower percentage than the reimbursement level indicated in your dental plan. For example, if your plan states that it will pay 80% of the cost of a specific treatment, it means 80% of the arbitrarily fee determined by the insurance company and not the actual fee charged by our dental office.
The financial obligation for dental treatment is between you and our office. The insurance company is responsible to you and your employer, and not to our office. We request that you pay your estimated portion at each visit. If, for any reason, we have not received your insurance carriers payment 30 days after claim submission, the total remaining balance will be due and payable by you.
IT IS YOUR RESPONSIBILITY TO ENSURE ALL INFORMATION TO US AND YOUR INSURANCE COMPANY IS CORRECT. WE WILL BE UNABLE TO SUBMIT OR COLLECT ON YOUR BEHALF IF THE INFORMATION ON FILE WITH US IS INCORRECT.
I have read, understand and agree to all terms as stated above. I agreed to pay all service charges that may be incurred should any balances remain unpaid after treatment.
I hereby authorize payment from my electrically submitted claim(s) be paid directly to West Grande Prairie Dental.