PATIENT CONTACT PREFERENCES

In general, the HIPAA privacy rule gives individuals the right to request a restriction of uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply)

� Home Telephone o OK to leave message with detailed information o Leave message with call-back number only

� Work Telephone o OK to leave message with detailed information o Leave message with call-back number only

� Cell Phone o OK to leave message with detailed information o Leave message with call-back number only o OK to text appointment information

� Written Communication o OK to mail to my home address o OK to mail to my work/office address o OK to email detailed treatment information and appointment information o OK to fax detailed treatment information to this number

Patient Signature /Guardian Date Print Name Birthdate

Designation for Release of Dental Information to a Family Member, Friend or Legal Representative

It is the dentists’ responsibility to ensure that the dentist-patient relationship is confidential. This form is an aid to the dentist in making a determination on disclosing such information. Dr. Dillard realizes that there are times when you, the patient, may want another person to be knowledgeable about your dental condition or dental needs. Your doctor wants you to be able, if you so desire, to name a person to whom you want the office staff to speak with about your dental condition. To enable that, we would ask that you complete the form listed below. Please note the following points:

• The designation is valid until you cancel it in writing. • If you designate no one, Woodland Hills Dental may not be able to release information to any

family member or friend.

Designation Statement

I, designate the following person to speak to a dentist at Woodland Hills Dental or other staff member on my behalf should it become necessary. I hereby give permission to Woodland Hills Dental, through its dentists and staff, to release to my designee any information about my dental needs and I release Woodland Hills Dental, its dentists and staff, from any claim of confidentiality in connection with the release of this information.

Name of Designated Person: Relationship:

Phone Number: (home / work / cell)

Patient’s Name: Patient’s SSN #:

Patient’s Signature: Date:

I decline to designate another person to speak with my dentist or clinical staff.

Patient’s Signature: Date:

Woodland Hills Dental

Acknowledgement of Receipt of Office Policies

HIPAA Notice – revised 9/15/2014 Financial Policy – revised 7/2014 Appointment Policy – revised 7/2014

These written policies are available to be reviewed and/or printed on our website:

woodlandhillsdentaltx.com

These written policies are also available at our office: 6617 Precinct Line Road, Suite 100, North Richland Hills, TX 76182

Please be sure to read our office policies and ask if you have any questions. We find that communication is important and we want you to feel comfortable as we partner together in maintaining your dental health.

I acknowledgement receipt of the above mentioned policies from Woodland Hills Dental.

Patient Name:_________________________________ Date:_________________________

Patient (or Responsible Party) Signature:__________________________________________

Revised 7/2014

Financial Policy

Thank you for choosing our office for your dental needs. Dental treatment is an excellent investment in an individual’s medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important life enhancing care. We are always available to answer your questions and/or assist you in any way we can.

At the onset of your treatment we will provide you with an estimate of the total fees expected. Please understand that it will be an estimate only. Treatment sometimes changes for a variety of unforeseen reasons.

Fees less than $300 are due and payable at the time treatment is rendered. We accept cash, personal checks, credit cards (VISA, MasterCard, Discover and American Express) and Care Credit.

For our patients with dental insurance: We are happy to assist you in filing the necessary forms to help you receive the full benefits of your coverage. When it comes to estimating insurance payments or coverage, we must also stress the word estimate, as insurance companies continue to surprise us at times. Please remember that the contract for your insurance coverage is between you, your employer, and your insurance carrier. If the insurance company pays more than expected, you will receive a refund. If they deny your eligibility after the fact, the balance becomes your responsibility.

Payment Options

Prepayment Courtesy:

We are happy to offer a 5% accounting courtesy for all treatment over $300 that is paid in full by cash or check, with no insurance assignment, prior to treatment commencing.

Payment as Services are Rendered: If you wish to pay the estimated amount for treatment at the time services are rendered, we gladly accept cash, personal checks, and most major credit cards. Because we cannot guarantee your exact insurance coverage, there may be a balance remaining after your insurance payment is received. Whenever choosing this option, we ask that you leave a credit card on file for any balance that may be owed.

Monthly Payment Plans Available for Amounts Over $300:

“Same as Cash” Six-Months Interest-Free Available through Care Credit

Extended Payment Plans – 24 to 60 Month Low Interest For financing $1000 and over Available through Care Credit

3 Equal Monthly Payments 25% initial down payment Guaranteed with major credit card

“Lay-Away” Plan Treatment commences after comfortable monthly payments are made which equal the estimated patient portion.

Any insurance estimate given by this office is not a guarantee of actual insurance payment. You are ultimately responsible for all charges incurred for dentistry performed upon yourself or your dependents in this dental office. Any insurance claim not paid in full after 60 days will become your responsibility to pay at that time. Any balance left unpaid for 45 days, without signed, written financial arrangements, will be assessed a $35 collection fee and will be turned over to TekCollect for collection. An NSF check or failed charge with your credit card on file will incur a $35 missed payment fee and any additional cost necessary to collect the payment (including but not limited to a $35 collection fee).

Revised 7/17/2014

APPOINTMENT POLICY

When we make your appointment, we are reserving a room for your particular needs. We plan very carefully to reserve the right amount of time for your visit so that we can respect your time and we ask that you extend the same courtesy to us. We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for the occasional unplanned emergency, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. We ask that if you must change an appointment, please give us at least a 24 hour notice*. This makes it possible to give your reserved room to another patient.

There is a $30 charge for changing/cancelling your appointment within 24 hours or not showing up for scheduled appointments.

Repeated cancellations or missed appointments will result in loss of future appointment privileges.

Appointments for treatment with oral sedation require a non-refundable, non-transferable deposit of $200. We will apply the deposit to your account when you arrive for your appointment. Since these are long appointments, the 24 hour notice does not apply. Please make sure when you schedule that you can keep the appointment. * Notice means calling in and speaking with us to change an appointment. Leaving a voice message or sending a message through our reminder system does not constitute giving us notice.