Wallace Group Dentistry » New Patient Forms

Insurance & Financial Responsibility
Who is the party responsible for payment?*
First Last
Are you currently insured?*
- Yes
- No
Is the patient the subscriber of insurance?*
- Yes
- No
Who is the subscriber of insurance?*
First Last
Relationship to Patient*
Subscriber ID
Insurance Company
Group Number
Group Plan Name
Is patient covered by additional insurance?*
- Yes
- No
Subscriber's Name*
First Last
Birthdate*
SSN
Insurance Company
Group Number
Group Plan Name
Insurance Assignment: I certify that I, and/or my dependents, have insurance coverage with the insurance company above and I assign directly to The Wallace Group Dentistry for Today, Inc. all insurance benefits, if any, otherwise payable to me for services rendered.

Financial and Personal Health Information: I understand that I am financially responsible for all charges incurred during treatment. I further understand that any insurance contract is between my insurance carrier and me and The Wallace Group Dentistry for Today, Inc. is not part of that contract. (As a courtesy to our valued patients we will submit your insurance forms initially. If problems occur with the insurance portion of your obligation, the balance in full will become due in thirty (30) days. We will provide information to assist with your carrier.)

Service Charges: I understand that a Service Charge will be imposed on each item of my account which has not been paid within thirty (30) days of the time the item was added to the account. The Service Charge will be computed at the rate of one and one-half percent (1.5%) per month or an Annual Percentage Rate of eighteen percent (18%). Further, I understand that the Service Charge on my account is computed by applying the periodic rate (1.5%) to the overdue balance of my account. The overdue balance is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during that time. The Minimum Service Charge is $0.50.

Past Due Accounts: I also understand that if my account becomes past due, all necessary steps will be taken to collect the debt. If the account is referred to a collection agency or a claim filed in court, I agree to pay all of the collection costs which are incurred. If the account is referred to a lawyer for collection, I agree to pay all lawyers’ fees which are incurred plus all court costs. In case of suit, I agree the venue shall be Hamilton County, Ohio.

Returned Checks: I have been advised that there is a Thirty-Five Dollar ($35.00) fee for any checks returned by my bank.

Missed Appointment Fee: Please provide a 24-hour notice for any cancellation to avoid a cancellation fee. We have reserved that time especially for you. The current cancellation fee is $70.00.

Privacy Policies: I have received or have been offered a copy of The Wallace Group Dentistry for Today, Inc.’s Notice of Privacy Policies. I understand that The Wallace Group Dentistry for Today, Inc. may use my health care information and may disclose such information for treatment, payment, and health care operations.
Signature of Patient, Guardian, or Personal Representative*
Address Where Form Is Being Signed*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Typed Name of Patient, Guardian, or Personal Representative*
First Last
Date*
Relationship to Patient

Reason for Upcoming Visit
Information Sharing
With whom may we share information regarding your treatment or account?
Name
First Last
Relationship
Bisphosphonates
Have you ever or are you currently taking or scheduled to begin taking any of the medications, alendronate (Fosamax®), risedronate (Actonel®) or ibandronate (Boniva®) for osteoporosis or Paget’s disease?*
- Yes
- No
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia®) or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?*
- Yes
- No
Date Treatment Began*

New Patient Form

Step 1 of 4

Patient Information

Insurance & Financial Responsibility

Information Sharing

Bisphosphonates

Dental History

Medications

Allergies

Health History