BILLING QUESTIONNAIRE

Patient Name _________________________________________________________________________________________

Home # ____________________________ Cell # ___________________________ O�ce # _____________________________

Address _____________________________________________________City_______________ State____Zip_____________

Email Address_________________________________________________________________________________________

Confirmation Request: Email Text Call

Birth Date ___________________ Age _________ Sex ________

If Minor, Parent’s Name: ___________________________________________________________________________________

Referring Dentist: _______________________________________________________________________________________

PRIMARY DENTAL INSURANCE INFORMATION

Name of Insured _________________________________________________ Relationship to Patient ________________________

Birth Date ____________________________________ Social Security #_____________________________________________

Name of Employer ________________________________________ Work Phone ______________________________________

Employer Address ________________________________________ City ________________ State ___________ Zip ___________

Insurance Company _______________________________________ Group# _________________ Policy/ID# __________________

Ins. Co. Address _________________________________________ City ________________ State ___________ Zip ___________

Do you have Additional Dental Insurance? YES NO If YES, Complete the Following

Name of Insured _________________________________________________ Relationship to Patient ________________________

Birth Date_____________________________________ Social Security #_____________________________________________

Name of Employer ________________________________________ Work Phone ______________________________________

Employer Address ________________________________________ City ________________ State ___________ Zip ___________

Insurance Company _______________________________________ Group# _________________ Policy/ID# __________________

Ins. Co. Address _________________________________________ City ________________ State ___________ Zip ___________

CANCELLATION POLICIESA $50.00 cancellation fee will be applied to appointments broken without 24 hours’ notice.

RESPONSIBLE PARTYWe submit to your insurance as a courtesy. You are still responsible for the balance. We are a dental o�ce, therefore no procedure here will be covered under your medical plan.

CREDIT TERMSPayment is expected at time of service unless prior arrangements have been made.

We expect that the account be cleared within 90 days. If �nancial arrangements have been made, the remaining unpaid balance may be subject to a FINANCE CHARGE at the periodic rate of 1.50% per month, which is an ANNUAL PERCENTAGE RATE OF 21.5%. We compute the FINANCE CHARGE by applying the periodic rate to the “adjusted balance” of your account. That balance is determined by taking the balance you owed at the end of the previous billing cycle and subtracting all payments and credits received during the present billing cycle. To avoid a FINANCE CHARGE pay the “new balance” shown on your billing statement before the next billing cycle.

There will be a $25 fee for all returned checks.

I have read and understand the above “Truth in Lending” disclosure, and I agree to the �nancial policies stated therein.

Signature ____________________________________________________________Date ___________________We accept cash, check, Visa, Mastercard, American Express, Discover, and Care Credit.

D R . M I C H A E L J . F L O R E N C E D R . J A C K H . L I N C K S D R . R A N D Y S . D E M E T T E R

B O A R D C E R T I F I E D P E R I O D O N T I S T S • S P E C I A L I Z I N G I N P E R I O D O N T I C S A N D I M P L A N T S

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