Health History
I understand that providing incorrect information can be dangerous to my health. I certify that I have read, understood and
completed the Health History Questionnaire fully and accurately to the best of my ability.
Release of Information
I understand that the dentist may need to call to collaborate with other healthcare providers and/or third-party payers in
order to provide the best standard of care for me. I authorize the dentist to release any necessary information, including
the diagnosis and the records of any treatment or exam rendered to me or my dependent during the period of dental care
to third-party payers and/or other health care providers related to my care.
Financial Policies
I understand that SWOSA gladly accepts dental insurance. In order to prevent any future
misunderstandings, disagreements, or disappointments, it is vital that our patients understand our relationship with
insurance companies. In the event that your insurance company refuses payment for services rendered, you will be
responsible for payment in full. A denial from your insurance does not release you from your financial obligation to us.
Every attempt will be made to help you get the proper benefit, but ultimately the final decision rests with your insurance
provider.
I understand that the dental office will make every effort to give me accurate estimates of what I will owe for each visit,
and that they cannot guarantee exactly what my insurance will pay. I understand that if I have dental insurance, this
is a contract between the insurance company and myself, and is ultimately my responsibility, not the dental office's
responsibility.
I understand that if any balance remains after my insurance company has paid a claim, I will receive a statement from the
dental office for this, and I am expected to pay in full within 15 days of receiving this statement. A late fee of 18% of total
balance or $25.00 (whichever is greater) will be applied to balances over 30 days.
I understand that I am expected to pay what is due for my treatment when I receive it.
I agree to be responsible for timely payment for all services rendered on my behalf or my dependent's behalf. I agree to
be ultimately responsible for all charges on my account which have been applied in accordance with established office
policy.
I understand that if my account remains unpaid, it may be transferred to a collections agency.
I understand that my account will be charged a $50.00 fee for any dishonored check and that I am expected to pick up
the check and pay the balance and subsequent fees in cash.
I understand that these policies may be superseded by a written and signed agreement of an alternate policy specific to
my account.
Rescheduling and Cancellation Policies
I understand that if I need to reschedule an appointment, or cannot keep an appointment, I must give 24 hours' notice to a
staff member. If I do not give adequate notice, my account will be charged a $50.00 cancellation fee.
I understand that if I fail or cancel more than 3 consecutive appointments without appropriate notice, my active patient
status will be reduced to emergency status, and I will be advised to seek an alternate dental provider.
Privacy Practices
I acknowledge receipt of Privacy Practices Notice (HIPAA) available upon request.