Azar & Kepic Periodontics & Dental Implants | 250 East 7th Street, Suite D, Upland CA, 91786 | 909-982-4169
Your general health constitutes an important factor, and in combination with other causes, may influence the course of periodontal disease. To assure your health during therapy and to assist in establishing a thorough diagnosis for successful treatment, please complete this confidential form.
Please check the appropriate box in answer to the following questions.
Patient Statement and Signature:
To the best of my knowledge, the above information I have noted is correct.
I understand I am financially responsible to Azar & Kepic Periodontics & Dental Implants for all charges for services received and that payment is due in full at the time such services are rendered. All accounts not paid within 30 days of treatment shall be subjected to a late payment fee of 1.5 % per month of the adjusted balance, or 18% annual percentage rate. Such late payment fee shall be waived for any account paid in full within 90 days of treatment. The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the treatment to be rendered to the patient, he/she hereby individually obligates himself/herself to pay Azar & Kepic Periodontics & Dental Implants in accordance with regular rates and terms of this dental office. Should accounts be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorney’s fees and collection expense.
Insurance is billed as a courtesy to the patient and is not an obligation. Any fees not covered by the insurance plan will be the responsibility of the patient. The undersigned authorizes, whether he/she signs as an agent or as a patient, direct payment to Azar & Kepic Periodontics & Dental Implants of any insurance benefits otherwise payable to or on behalf of the undersigned for treatment rendered. It is agreed that payment to Azar & Kepic Periodontics & Dental Implants, pursuant to this authorization, by any insurance company shall discharge said insurance company of any and all obligations under a policy to extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.
Any condition precedent to recovery or administrative appeals required by the policy shall be the sole responsibility of the patient/guarantor, and not Azar & Kepic Periodontics & Dental Implants. This is requirement shall apply to any and all treatment rendered by Azar & Kepic Periodontics & Dental Implants and his staff.
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
I have been informed of my dental providers Notice of Privacy Practices containing a more complete description of the uses and disclosure of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain the current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you agree then you are bound to abide to such restrictions.
For Office Use Only:
We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due the following reason: