Irp-cdn.multiscreensite.com



3105150-4508500 PETERSON FAMILY DENTAL1930 Hart Street Dyer, IN 46311P: 219-836-8886 F: 219-836-8846Office PoliciesThank you for choosing Peterson Family Dental. Please take a few minutes to review our office policies.Registration and Medical History: Please answer all of the questions on the registration form to the best of your ability. If you are unsure how to answer a question or if it is unclear what the question is asking, please ask the doctor or a member of our team for clarification. Your oral health is part of your overall health. It is important that we have a complete and current medical history so that we can treat you safely and effectively. Please update us of any and all changes in your medical history, medications, and allergies at the beginning of each visit to our office.Examinations and Oral Cancer Screenings: Peterson Family Dental requires that an examination, including any radiographs deemed necessary by the dentist, be performed at least once per year before any treatment is performed. This includes preventative treatment such as cleanings and fluoride applications.An oral cancer screening will be performed at every comprehensive and recall examination at no charge. We will notify you verbally of any abnormal findings. Certain abnormal findings may require further diagnostic procedures to be performed or may require a referral to a dental specialist. These diagnostic procedures and specialist visits may or may not be covered by your insurance.Patient Safety and Infection Control: Peterson Family Dental strives to meet government regulations concerning infection control. Our patients’ safety is our utmost priority. As such, we ask that you respect the following office policies:No food and/or drinks are allowed in or beyond the reception area.During patient treatment, only the patient being treated is allowed in the operatory.If a child under 5 years old is accompanying you to your dental visit, another adult must be present to watch over the child during the appointment.A parent or legal guardian must accompany any patient under 18 years old to all appointments, unless they provide signed consent for the patient to be seen with another caretaker.Insurance: Peterson Family Dental accepts all insurance plans, but the providers at Peterson Family Dental are not in network with all insurance plans. The providers at Peterson Family Dental are in network with several Delta, Cigna, and Anthem insurance plans. We will contact your insurance provider to check your benefits and eligibility. Please note the information provided to us by the insurance company is not a guarantee of benefits or eligibility. If you have any questions or unsure of your eligibility, benefits, or whether we are in-network with your specific plan, we encourage you to contact your insurance provider directly for clarification. You will be responsible for any expenses not payed or adjusted for by your insurance carrier. At your request, we will send a pre-determination of benefits to your insurance company for any planned treatment. Please note information received by your insurance company in a pre-determination of benefits is only an estimate and not a guarantee of benefits. The information is subject to change if your benefit period ends or the terms of your plan change.Payment: All out-of-pocket expenses, coinsurance, and deductibles are due at the time of your visit. Payment for certain procedures is required before treatment begins. If you choose to discontinue care before treatment is started, a check refund will be issued to you. If you choose to discontinue care after it is started but before it is completed, a refund will be determined upon review of your case. Payments may be made by cash, check, or credit card (Visa, Mastercard, American Express, or Discover). We also accept payment via CareCredit and LendingClub. These are convenient monthly payment plans that allow you to pay for treatment over time with little or no interest and without annual fees or pre-payment penalties. If you are interested in hearing more about CareCredit and/or LendingClub, please ask a member of our front desk for information of how to apply.Checks are payable to Dr. Peterson. A $35 fee will be charged for any returned checks.Cancellations/Missed Appointments: If you need to cancel or reschedule your appointment, we ask that you provide us with 24 hours notice. Any patient who has missed or cancelled 3 appointments without 24 hours notice within a 12-month period will be charged a $40 broken-appointment fee.I have read and accept the office policies. __________________________________________________________________________Patient’s Signature Date(Guardian’s Signature if patient is under 18 years of age)We provide our patients the option to participate in our online patient communication system. Some of the features include:Appointment requests onlineReceive text message appointment remindersConfirm appointments via e-mail or text message Submit patient satisfaction surveysRefer friends onlineYou may opt out of communications at any time by clicking the unsubscribe link in the footer of each e-mail or by replying “STOP” to any text message sent by us. Standard text messaging rates apply.Would you like to be added to our patient communication system?□ Yes, add me to the patient communication system.The best phone number to text me is: ________________________________ □ Cell □ Home □ WorkThe best e-mail to contact me is: ____________________________________________________________________□ No, I do not wish to be added to the patient communication system at this time.We may disclose patient health information (PHI) to third parties that perform services for Peterson Family Dental in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law. Our affiliates will not send e-mails, spam, or any other communications without user permission.______________________________________________________________________________________________________Patient’s Signature Date(Guardian’s Signature if patient is under 18 years of age) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download