By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Tender Care Dentistry "Notice of Privacy Practice" provides information about how we may use and disclose protected health information about you. Please acknowledge receipt of this office’s notice of Privacy Practice by initialing below.
Our Notice of Privacy Practice states that we reserve the right to change the terms described.
You have the right to request restrictions on how our protected health information may be used or disclosed for treatment, payment or health care operations. We are not required to agree to your restrictions, but if we do, we are bound by our agreement with you.
By signing this form, you consent to our use and disclosure of protected health information about you for the treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in trust on your prior consent.
Dear Tender Care Dentistry
I , give authorization to approve any treatment may need during his/her dental visits in your office.
By initialing this section you give Tender Care Dentistry permission to take a photo of your child for identification purposes and in office use.
You MUST confirm your appointment by 3pm the day before your scheduled appointment. If appointed on a Monday you must confirm by 3pm the Thursday before. Failure to confirm will result in forfeiting your appointment time. Confirmations can be done via text, email or phone call.
In order to give you and your child the high quality service you deserve it will be necessary to keep all scheduled appointments. If you absolutely cannot keep the appointment it will be mandatory for you to notify us within 24 hours of your appointment.
The use of cell phones and other hand held devices are extremely disruptive. The use of Cell phones is prohibited outside of the waiting room area.
Eating or drinking within the dental office is prohibited. For safety reasons, OSHA prohibits any food or drink to be consumed in the clinical areas.
By signing below I acknowledge that I have read and understood these policies.
Credit Card Signature Authorization: Signing this section will enable you to make credit card payments over the phone to pay on your account at Tender Care Dentistry. Without a valid signature on file we will be unable to process credit card payments via telephone.
Primary Insurance: As a courtesy, Tender Care Dentistry will file the primary insurance claim for you. Our helpful staff will attempt to ESTIMATE your insurance benefits as accurately as possible. However, changes in benefits and exclusions unique to your policy may result in a refund or balance due after your insurance has paid. Please be familiar with your insurance benefits to help us with this process.
Please remember that your insurance policy is a contract between you and your insurance company; we are not a party to that contract nor are we responsible for procedures that are not covered for any reason. We must have complete and up to date insurance information in order to bill your insurance company on your behalf. In the event that your insurance company has not paid their portion within 60 days the balance will become your responsibility.
Secondary Insurance: Tender Care Dentistry will no longer file any secondary claims unless you are primarily covered by the Federal Blue Cross Blue Shield plan or if your secondary insurance is through the Maryland Medical Assistance Program.
Returned Checks: All checks are electronically deposited in real-time on the day they are written. A $35 fee will be applied to any returned checks.
Unpaid Accounts: Any account 90 days past due may be sent to a collection agency or settled in small claims court. In these events, you will be responsible for any collection and/or court fees incurred.
I, , authorize Tender Care Dentistry to email my child’s, , x-rays directly to another dental office for any of the following reasons:
In the event Tender Care should refer my child to another dental office or specialist for a consultation and/or treatment.
In the event I choose to transfer my child to another dental office for a consultation and/or treatment.