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 authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Dr. Scheller would like to thank you for your cooperation on this important matter. The information requested will help him to identify what medications to prescribe and treatment to be given.
Failure to disclose may result in dismissal from the practice. DEA reports may be pulled on Patients requiring Narcotic pain medication.
Your privacy is very important to us at Viewmont Family Dentistry. We promise to take every precaution to protect your rights to having your health care information secure. Our formal notice of privacy practices is located in the waiting area. You can read this while waiting for your visit.
You are entitled to copy of our Notice of Privacy
Practices, which will be located at the reception area.
We also need to ask our patients how they wish to be notified about future appointments for check ups and restorative treatment. Usually, we try calling our patients to confirm the appointments at least 24 Hours in advance. If we are unable to contact you, we leave a message on your answering machine, with a family member, or co-worker.
Please answer the following so that we may comply with your wishes concerning appointment notification:
Polices and Agreement for Patients with Medicaid and NC Health Choice
Unfortunately, it has been our experience that patients with Medicaid and NC Health Choice have had an extremely high number of broken appointments. The result of those numerous broken appointments have been unnecessary and sometimes painful to other patients in need of treatment. Therefore, the following policies have been implemented to eliminate broken appointments and to treat motivated patients in a more timely manner.