Patient Intake Form for Bonnie Doon Dental Associates

I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.

I understand that responsibility for payment of fees associated with dental services (in whole or any portion not covered by my insurance) is mine, due and payable at the time services are rendered unless other arrangements have been made, including any assessment for short notice cancellations for hygiene appointments.

I permit Bonnie Doon Dental Associates to submit pre-authorization to my dental benefits plan administrator for dental Exams, procedures and routine care appointments. I authorize release, to my dental benefits plan administrator, information contained in claims submitted electronically. I hereby assign my benefits, payable from claims submitted electronically to Bonnie Doon Dental Associates and authorize payment directly to them. This authorization shall continue in effect until the undersigned revokes the same.