1.I hereby authorize doctor or designated staff to take x-rays, study models photographs and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis.
2.Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3.I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4.I give consent to the doctor's or designated staffs use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
STREITZ DENTAL ARTS, LTD
In order to avoid any misunderstanding regarding our financial policy, it is necessary for you to read and sign this document
DENTAL INSURANCE: As a courtesy we will gladly file your claims provided you agree to the following:
- You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim.
- Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract.
- If we are not an "in-network" provider of your insurance you are responsible for our fees and not what your insurance company allows or considers "usual, customary and reasonable" fees. We will be happy to submit a dental claim to expedite the reimbursement.
- Although we may estimate your insurance benefit's we are not responsible for their accuracy. Receiving our services indicates your acceptance of responsibility to pay regardless of your estimate.
- All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. If your insurance fails to pay, you will be responsible for the balance on your account.
- Not all the services we provide are covered benefits. Benefits differ by dental plan. Fees for non-covered services along with deductibles and copayments are due at the time of service.
- I understand I am financially responsible to Streitz Dental Arts, Ltd. for charges not covered by this assignment, and that credit checks and reports may be liable for any charges not paid by my insurance company that were incurred by children or dependents of mine over the age of 18 who are listed or covered under my Dental Insurance. I agree to pay any reasonable attorneys fees or court costs incurred by Streitz Dental Arts. Ltd. in the event that I fail to pay the amounts due for services rendered and this account is sent to an attorney or collection agency. I also agree to pay collection service fee.
PATIENTS WITHOUT INSURANCE COVERAGE: We provide written estimates of fees, and payment is expected at each visit for services rendered.
PAYMENT POLICY: We accept cash, personal checks and credit cards. Third party checks are not accepted.
RETURNED CHECKS: A $10.00 charge will be applied when a check is returned by the bank. Non-payment checks not reconciled will be sent to the State's Attorney's Office.
CANCELLATION/NO SHOW POLICY: A fee of $75 will be applied for a no-show appointment, or if an appointment is cancelled or broken without a 24 hour notice. We reserve the right not to make future appointments if this occurs more than twice. Streitz Dental Arts. Ltd.defines "no-show" appointments as any scheduled appointment in which the patient either:
- Does not arrive to the appointment
- Cancels with less than 24 hours' notice
I have read and understood the Streitz Dental Arts, LTD agreement as described above.
We strive to provide a safe environment for our patients and staff, and to advance the safety of our community. However, the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. There are numerous ways in which the COVID-19 virus can be transmitted, including from the surface contact, respiratory droplets and aerosols, or fine particles that travel with air currents. Dental procedures create aerosols, the amount of which depends on the type of procedure. While we are committed to providing the safest environment as possible for our patients, there can be no guarantee that our facility is completely free of the COVID-19 virus and that you will not be exposed to the virus while receiving treatment despite our efforts to minimize the risk of exposure.
By signing this Consent and Release in the space provided below, you hereby release, acquit, waive all claims against, and forever discharge the practice providing my treatment (the "Practice") and its owners, successors, assigns, affiliates, officers, directors, administrators, representatives, principals, agents, dentists, employees, independent contractors, insurers, and attorneys (collectively with the practice, the "Indemnified Persons"), of and from any and all claims, charges, demands, promises, acts, agreements, costs, damages, debts, obligations, actions, causes of action (including but not limited to all avoidance actions of any type), suits in equity, expenses, executions, judgements, levies, liabilities, losses, and direct or indirect, suspected or unsuspected, accrued or unaccrued, known or unknown, present or future, asserted or unasserted, based upon, arising out of, appertaining to, or in connection with your exposure to the Severe Acute Respiratory Syndrome Coronavirus 2 or contracting coronavirus disease (COVID-19) as a result of or in connection with your entry into the Practice's office, receipt of dental treatment from the Practice or coming in contact with and Indemnified Person at the Practice's office, and all related costs, expenses, illness, or death you may suffer as a result.
The releases set forth and otherwise referenced herein shall be interpreted as broadly as possible and shall be completely binding and enforceable at law. You acknowledge that the releases and waivers provided for herein include all claims and/or costs, including but not limited to those you do not know or suspect to exist, and hereby waive all rights which may exist with regard to such claims and/or costs. You expressly waive the provisions of any federal, state, and local statute or regulation limiting release of unknown claims, including any statutory language stating as following: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY, AND ANY SIMILAR LAW."
You agree that you have had the opportunity to consult with an attorney prior to executing this Consent and Release, that you voluntarily have signed the same and that you have read and understand this Consent and Release. YOU FULLY UNDERSTAND THAT, BY SIGNING THIS CONSENT AND RELEASE, YOU ARE WAIVING IMPORTANT LEGAL RIGHTS.