Patients:

Below is a copy of our office policy. It is required that all new patients sign a copy, and all current patients re-sign upon each update. We are providing a copy here for your review, so you know policy and expectation in advance of your first visit. Should you have any questions please do not hesitate to contact our practice directly by phone or email.

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Overall Policy:

It is our pleasure to assist you in obtaining your maximum benefit. Your benefit program is a contract between you, your employer, and the insurance company. We encourage you to become familiar with you plan as well as any exclusions, deductibles, co-payments and yearly maximum. While understanding your insurance coverage may be challenging, our goal is to assist you in maximizing your benefits. We will file your insurance claims for you and do whatever we can to help with this process. Both the deductible and the estimated co- payments are due at the time of treatment unless other arrangements are made. Our estimates are subject to final approval by your insurance carrier. You are advised to monitor your own insurance. This office is not responsible if payable benefits exceed your yearly maximum. Unless special arrangements are made, full payment is due upon completion of active therapy. I thereby authorize the release of medical information to any of my health care providers or insurance companies that may be pertinent to my case. I hereby authorize direct payment of insurance benefits that are otherwise payable to me to Dr. Shivangi Amin. I hereby authorize the release of my medical records to third-party insurers or other persons to whom disclosure is necessary to establish or collect a fee for all the services provided. I understand that I am financially responsible for charges arising from the treatment of myself (or the above named patient, if applicable). I understand that payment in full is due at the time services are rendered; however, I agree to pay a FINANCE CHARGE of 1.5% per month on balances over ninety (90) days past due, which is an annual percentage rate of 18%. IF my account is referred to an attorney for collection, upon said referral, I agree to pay attorney's fees in the amount of thirty-three and one-third (33-1/3%) of the total outstanding indebtedness (which includes, but is not limited to, principal, accrued interested and late charges) then due, and all costs of collection. I agree to pay the aforesaid attorney's fees and costs of collection whether or not the attorney files suit. A photocopy of this contract shall be considered as valid as the original. Any checks received as payment on this account and returned by the bank unpaid for any reason will be charged $50.00 each time.

 

In addition, in accordance with section 32.1 45.1 of the code of Virginia, 1950, I shall be deemed to have consented to testing for infection for Human Immunodeficiency Virus (HIV) and to the release for such test results to the person(s) exposed.

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Office Obligations

1. File the insurance claim in a timely manner requesting payment of your benefit to our office.

2. Research and explore your policy to advise you of your benefits.

3. Re-file your claim if necessary (a second time).

4. Follow accepted guidelines for submission of claims.

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Patient Obligations

1. I understand that a charge of $75.00 per one-half (1/2) hour for all missed or broken appointments will be made unless forty-eight (48) hour notice has been given (except in an emergency).

2. Payment of fees (not covered by insurance) at the time the services are rendered. I understand that in the Commonwealth of Virginia, Dr. Amin is allowed to bill the current office fees for any services that are not being covered by the insurance [a copy of these fees is available upon request] I further understand that the office may not know that said services are non-covered benefits.

3. I understand that the insurance policy belongs to me and we have no leverage to obtain payment from the carrier.

4. Taking responsibility for payment if the insurance carrier does not pay our offices within 60 days.

5. I will make sure to inform your office of any changes in my insurance coverage.

6. Two (2) missed appointments result in a failure to comply with treatment and may result in discontinuation.

7. We require a payment of 20% of your estimated co-pay to schedule all surgery appointments that is NON-REFUNDABLE if cancelling or missing an appointment (except in an emergency).

8. We will collect 2% on all credit card payments totaling $1,500.00 to $2,000.00 and 3% for anything $2,000.00 or more. To avoid this fee, we accept cash or check.

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I hereby authorize Dr. Shivangi Amin to release to my insurance carrier information acquired in the course of my therapy. I authorize benefits to be paid to Dr. Shivangi Amin. I understand I am responsible for any unpaid balance. Sign Form to the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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