GAINESVILLE FAMILY DENTAL CENTER

Margaret P. Stubblefield D.D.S., P.C.

General and Cosmetic Dentistry

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Financial Policy and Arrangements

 

Dr. Stubblefield and our team would like to welcome you to the practice.  We are committed to providing the best dental care for your particular needs.  We will, however, only be able to accomplish this by spending the time necessary to diagnose and treat your dental needs. This treatment is very important to your health and should not be postponed by financial concerns.

 

To enable you in proceeding without delay, our office offers several financial options.  Dr. Stubblefield’s philosophy is to make dentistry affordable to everyone and we hope this helps you make us your dental home.

 

Text Box: We accept Cash, Check, VISA, Mastercard, and American Express. If you have dental insurance, we will do our best to estimate your co-payment. The estimated co-payment will be collected from you at the time services are rendered. As a courtesy, we will file your primary insurance electronically. You will be billed for any remaining balance after we receive your insurance payment. Secondary insurance coverage will be your responsibility to file. Dental Fee Plan applied for through Capital One ®

 

Dental Insurance:

 

I understand my dental insurance is a contract between the insurance carrier and me, not between Dr. Stubblefield and the insurance carrier.  As such, I understand that I am responsible for the full amount of all dental treatment incurred.  Any payments received by Dr. Stubblefield from my insurance carrier will be credited to my account or refunded to me if I have paid the dental fees incurred.

 

Financial Responsibility:

 

I/We agree and personally guarantee, in consideration of services and materials provided by Dr. Stubblefield, to be responsible for payment in full of the dental bill.  If the balance goes over 90 days there will be a 1.5% finance charge added to the balance per billing cycle.  In the event that this matter is turned over to an attorney for collection, I/We agree that I/We shall pay twenty-five percent (25%) attorney’s fees and interest on the unpaid principle balance at the rate of eighteen percent (18%) per annum..

 

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Responsible Party’s Signature                                    Date

 

 

 

NOTICE OF PRIVACY PRACTICES

 

· I understand that my healthcare information concerning my diagnosis, treatment, payment and insurance will be disclosed when necessary for filing my insurance and in communicating with other health professionals in the course of my treatment or their offices.  Limited information will also be disclosed to businesses supporting the operations of this office such as dental or medical labs, hospitals, accountant, computer support, billing personnel, answering services and consultants.  These businesses are restricted in the use and disclosure of your information by contract.  Disclosure may also occur for any necessary legal purposes or appropriate government authorities.  If a family member or person is paying for your healthcare with your knowledge, we may disclose information to that family member or person.

· I understand that my files are stored on shelves in the business office.  Only staff and janitorial personnel may have access to this office during non-business hours.  I understand that this office will make every effort to keep my information secure and correct any violation of my privacy if this should occur.

· I understand that I have the right to access, copy or inspect and correct my healthcare information, the right to restrict disclosures and obtain and accounting of disclosures.  I have the right to voice my concerns about privacy to the practice and/or the Secretary of Health and Human Services within 180 days of my discovery of a disclosure violation without fear of retaliatory acts by this office.  I may correct my records in the form of a letter signed by me.  I also have the right to revoke my authorization for disclosure.  A minimal fee of $0.20 per page will be charged to me for copies of records that I request.

I understand that I will receive communication in the form of phone calls and/or postcards to remind me of an existing appointment, or that it is time to schedule an appointment.  I may receive mail containing financial information such as ledgers or bills.  Communication may also be sent to me in the form of fax, emails or other electronic means.  I understand that if a message is left for me to return a call, the message will contain the doctor’s name and phone number.  Complete messages concerning my health information may be left on my personal home or work voice mail.

 

 

I have read and understand this office policy.  I understand that by signing this agreement, I give my permission for the use and disclosure of my personal and health information in order to carry out treatment, payment activities, insurance claims and health care operations.  This office retains the right to revise the privacy policy. 

 

 

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Responsible Party’s Signature                                                                 Date