Patient Information

Responsible Party Information

Please complete this section if someone other than the patient is financially responsible for the account
(including parents or legal guardians).

Other Contact Parties:

By law, we are not able to discuss your dental care or personal information with anyone other than yourself (except for minors). If you give permission for us to speak with other persons about your appointments or treatment, please list their name(s) below. (Such asspouses, siblings, adult parents, etc)

Financial Agreement

I grant my permission for your office to communicate (phone, email, text, etc) with me at my home or my work to discuss matters related to these forms, financial arrangements, or my dental treatment.

If you have dental insurance, please provide the below information

 

Dental Insurance

Information regarding dental insurance (please read):

Dental Insurance is a financial assistance program designed to alleviate the high costs of dental care. There are limitations to benefits including annual maximum coverages, procedure-based benefits and frequency of hygiene visits which may not cover the entirety of your treatment. We typically do not recommend waiting to perform necessary dental treatment, which may lead to more out-of-pocket expenses. Please ask us if you have questions regarding your plan.

In/Out of Network:

We are contracted ‘in-network’ providers for some insurance networks, but can work with almost all other PPO plans to help maximize your benefits on an ‘out-of-network’ basis. For some companies, the difference between “in-network” and “out-of-network” benefits may be very minor.

Co-payments and Out-of-Pocket:

As a courtesy to our patients, we will bill dental insurance companies for treatment rendered. Although coverage amounts vary per plan and per procedure, we will do our best to estimate your co-payment amounts. With all dental insurance companies, these are estimates and can change, pending your benefits and decisions by insurance companies about your coverage. When we receive reimbursement from your company (typically 2-3 weeks), we will notify you if there is any remaining balance.

Please understand that all dental treatment is performed for the patient and that you or your responsible party are personally responsible for payment of all treatment, regardless of final insurance rulings and decisions.

Insurance Information

Secondary Insurance (if applicable)

Please sign, indicating acceptance of the above information.

Thank you for choosing Citracado Dental Group as your partner in dental health! To help us understand your personal needs, please complete the medical history form below to the best of your ability

Do you have an allergy or unusual reaction to any of the
following?

WOMEN ONLY:

Family Medical History:

Medications:

Have you ever taken oral or IV Bisphosphonates?

Dental:

I understand that dental providers must be aware of my current health status, and will inform them if there are changes to
my medical history.