Whittle Family Dentistry

William C. Whittle, DDS

William D. Whittle, DDS

310 Mercedes St.

Benbrook, Texas 76126

(817) 249-5522

Financial Policy

We want to thank you for choosing us as your dental care provider. We are committed to your

treatment being successful. Please understand that payment of your services is considered part of

your treatment. Because of this, we have adapted a simple financial policy for ALL of our

patients. Please read and sign this policy prior to any treatment being started.

In an effort to provide high quality care to all of our patients, payment for services is due in full

at the time services are rendered. We accept cash, checks, Visa, MasterCard and American

Express and Care Credit.

Please read and initial each line item below:

_____ (Initial) Dental Insurance- Please be aware that even if you have dental insurance, you are responsible for any deductibles, co-pays, and the amount we have estimated your insurance will not cover at the time of your appointment. Any charges/balances are your responsibility whether your insurance pays or not. It is in your best interest to know exactly what your insurance plan covers. Please understand that your insurance policy is a contract between you and your insurance company. Our office holds no party to that contract and will not be responsible in the event your insurance company denies any claim.

_____ (Initial) Cancellations & Missed Appointments- Your appointment time is reserved for

you. If you are late for your appointment, we may not be able to accommodate you. If you think

that you will be late, please call as soon as possible so that we may advise you if your late arrival

can be accommodated, or we will need to reschedule you. We maintain a very strict schedule

and must insist that appointment times be respected. For cancellations we require 24 hours

advance notice. If you fail to notify us within the 24 hour period, you will be charged a late

cancellation fee of $50.00 will apply and future appointments may require a deposit prior to

scheduling. Three missed appointments may result in dismissal as a patient.

_____ (Initial) Balances over 90 days will be charged a late fee of $15.00 each billing cycle, so

please be sure we have the correct insurance information, home mailing address, home phone

number or cell phone number on file for you.

Thank you for reading and understanding our Financial Policy. Please let us know if you have

any questions or concerns.

Patient (or Legal Guardian) Signature Date

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date: Patient Name:

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM RECEPTION AREA:

❑ First Name Only ❏ Proper Surname ❏ Other _____________________

PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND WHO CAN HAVE ACCESS TO

YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name:

Name:

Relationship:

Relationship:

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

❑ Cell Phone Confirmation

❑ Text Message to my Cell Phone

❑ Home Phone Confirmation

❑ Email Confirmation

❑ Work Phone Confirmation

❑ Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

❑ Cell Phone Confirmation

❑ Text Message to my Cell Phone

❑ Home Phone Confirmation

❑ Email Confirmation

❑ Work Phone Confirmation

❑ Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on

behalf of this Healthcare Facility via:

❑ Phone Message

❑ Text Message

❑ Email

❑ Any of the Above

❑ None of the Above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowl- edge and consent.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL

ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO

OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please print name of Patient Please sign Patient / Guardian of Patient

Legal Representative / Guardian Relationship of Legal Representative / Guardian

OFFICE USE ONLY

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

❑ It was emergency treatment

❑ I could not communicate with the patient ❑ The patient refused to sign ❑ The patient was unable to sign because

❑ Other (please describe)

Signature of Privacy Officer

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