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At South Cambridge Dental all professional dental services are performed by licenced members of the Royal College of Surgeons ( “ Dental Professionals”), and all institutional health care services are preformed independently by South Cambridge Dental Health Services, under the clinical supervision and control of Dental Professionals in a cost-sharing arrangement. South Cambridge Dental and South Cambridge Health Services are each independent entityproviding services but for ease of administration may render joint invoices for their respective services. One or more of our dental professionals may have a financial interest in South Cambridge Dental Health Services.

By signing this form, you acknowledge and agree that (i) you have read and understood the above information prior to any professional services being provided to you by any dental professional; (ii) you have been provided and have read a copy of the Privacy Code forSouth Cambridge Dental; (iii) you agree to the collection, use and disclosure of your personal information in accordance with the Privacy Code. You can withdraw your consent at any time on the understanding that withdrawing your consent to certain information handling practices may impair the ability of South Cambridge Dental to provide the service you are requesting.

I, the undersigned, certify that I have provided and accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding my medical –dental history. Should there be any change in either my health status or any other information I have provided, I will advice South Cambridge Dental immediately.As discussed with me, I authorize the dental professionals and all professional staff working under the supervision and control of the dental professionals to perform diagnostic procedures thatmay be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and I authorize the exchange of my personal information among South Cambridge Dental andSouth Cambridge Dental Health Services, my medical doctor and another health care provided with a copy and that my personal information will be collected , used and disclosed within the guidelines of the Privacy Code. I also understand that my personal information will be retained by South Cambridge Dental and South Cambridge Dental Health Services in accordance with their current practices, which may involve transfer and retention outside of Canada. I, the undersigned acknowledge that the South Cambridge Dental and South Cambridge Dental Health Servicesare relying upon the information which I have provided being accurate and complete.

Financial Policy and Agreement

South Cambridge Dental files the primary and secondary insurance claims on behalf of patients and requests their insurance company to pay the dental office directly. Patients are required to pay the remaining balance if the insurance company does not pay in full payment. We cannot waive co- payments and deductibles. This payment is required at the conclusion of appointment.

We handle all billing details with the insurance company. If the insurance company denies payment to the dental office directly, the patient will be notified, and the patient will be responsible for payments to the dental office and collecting the money from their insurance company.

Walk- in and emergency patients pay the dental office and claim the money from their insurance. However, we will file the claim for you electronically.

Payment in full is due atthe time services are rendered unless prior financial arrangements have been made. We accept Visa, Mastercard, Debit and Cash. Personal cheques are not accepted.

Patients are provided with their bill and encouraged to review and understand what treatments were carried out. It is important you understand the codes and procedure taken place.

Your insurance claim form will be transmitted automatically to your carrier over the internet. A claim acknowledgement form will come directly from the insurance carrier. This form verifies that they have received your dental claim for processing, or an “explanation of benefits” form. Which indicated the exact amount of the claim which they will pay and your portion that is not covered.

Unfortunately, not all insurance companies accept electronic submission. Therefore, we may need you to sign a manual claim form for processing.

Our office is committed to helping patients maximize their benefits and insurance policies vary greatly. Therefore, you are fully responsible for knowing your own dental insurance and what you are not covered for. Treatment is recommended based on what you need NOT on what is covered by your plan.

It is not always possible for us to find all the information concerning your insurance plan, as insurance companies are not obligated to disclose any or all information us under the privacy act. We recommend that patients verify their coverage with their insurance coverage.

Insured patients are encouraged to provide us the following information about their insurance policy. If in doubt, always ask the insurance company. Information required:

    • Name of Insurance Carrier
    • Policy number, certificate number (ID)and division number (if any)•The anniversary date of the policy, for example Jan 1stor rolling calendar year
    • The annual maximum benefit per patient per year
    • The annual fee guide covered by their insurance policy (2011, 2012, and 2013 etc.)
    • Percentage of coverage for procedures (restorative, preventative, endodontics, periodontal services and all other major treatments, such as dentures and crown & bridge
    • The per person and family annual deductible amount
    • Number of scaling units covered per year and frequency etc...

As a courtesy, we will gladly send your claim electronically for you, on your behalf to your insurance company providing that your company does allow electronic submission (EDI).

A parent or guardian must accompany all minors to their dental appointments. The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payments and discussing other treatments that need to be done with there child’s mother or father. Payments must be collected the day of the appointment from the parent accompany without any exception. This office will not attempt to collect payments from the other parent that was not present the day of the appointment, therefore this is not our responsibility.

Once an appointment had been made a room is reserved specifically for you. Please respect our time and spot reserved for you. Please consider calling our office two business days to reschedule or cancel an appointment in order to avoid a $50.00 service fee.

Service charges are applied on all overdue accounts. We understand temporary financial problems may affect timely payment of your balance in some cases. In those situations, we encourage you to communicate any such problems immediately to our front desk team at 226-318-0927 they can be reached during regular business hours.