Oak Street Dental - Intake Form

Insurance Information

Primary Dental Insurance Provider

Employer

Policy or Group #

ID or Certificate #

Plan Holders Name

Plan Holders Date of Birth

Basic Coverage %

Major Coverage %

Annual Limit $

Recall Schedule

Root Planning & Scaling Units

Yearly Deductible

Yes No

Are composite (white) fillings covered on molar teeth?

Yes No

Secondary Dental Insurance Provider

Employer

Policy or Group #

ID or Certificate #

Plan Holders Name

Plan Holders Date of Birth

Basic Coverage %

Major Coverage %

Annual Limit $

Recall Schedule

Root Planning & Scaling Units

Yearly Deductible

Yes No

Are composite (white) fillings covered on molar teeth?

Yes No

I authorize release; to my dental benefits plan administrator and the CDA, to release information contained in claims and preauthorizations submitted electronically and manually. I also authorize communication of information related to the coverage details and services described to the named dental office.
This authorization shall continue in effect until the undersigned revokes the same.

ASSIGNMENT OF BENEFITS

I hereby assign my benefits, payable from claims submitted electronically and manually, to the treating doctor at Oak Street Dental and authorize payment directly to him/her.
This authorization shall continue in effect until the undersigned revokes the same.

I understand that Oak Street Dental is a third party company and that my insurance policy is an agreement between me, my employer and the insurance company. I understand that though Oak Street Dental has my plan on file and submits claims on my behalf, that I am ultimately responsible to know my plans details and guidelines and that I am financially responsible for any treatment not covered under those guidelines.

I have reviewed the above assignment of benefits*

OFFICE POLICIES

All patient balances are due immediately after treatment is rendered.

Should a balance accrue on the account a statement will be sent and payment is to be made, in full, within 15 days of the date on the statement. If payment is not paid within 30 days interest at the rate of 1.5% per month will be applied to the entire account balance. A revised statement with the new account balance, payable immediately, will be sent.

If no effort is made to clear the account within 90 days of the initial statement date a $50 dollar administration fee will be applied and the account will be sent to collections. All booked appointments will be cancelled and no further appointments will be booked. This applies to all patients on or connected to the delinquent account.

A $20 NSF fee is applied to all patient cheques rejected by the financial institution.

Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by the dentist, not an obligation. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.

If there is dental insurance on the account, I understand that the clinic has established the patient balance based on the information I have provided. Final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment is received from my insurance provider, no patient payment is final.

Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total.

Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics.

A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible. The clinic will make every effort to accommodate my scheduling needs.

I have reviewed the above office policies*

CANCELLATION POLICY

I have a time reserved for my appointment. Oak Street Dental requires that any changes to appointments are made with a minimum of 48 hours. If I fail to confirm my appointment the appointment will be removed from the schedule. If I do not keep the appointment and/or fail to notify the clinic with the required notice, a $125 fee will be applied to my account. If I fail to arrive for an appointment on a Saturday, I will no longer be able to reserve Saturday appointments unless I pay a $125 fee.

That appointment cancellations and/or rescheduling must be communicated directly to a representative of the clinic. Cancellations and/or rescheduling are not accepted via email, text or phone message and if done so the above noted cancellation deposit will apply.

I have reviewed the above cancellation policy*

To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information may be dangerous to my (or patients) health.

Signed by *

Please leave this field empty

I have reviewed the privacy consent policy (click here to review).*

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Contact Information

How did you hear about us?

Emergency Contact Information

Family Doctor Or Walk-In Clinic Information

Insurance Information

I have reviewed the privacy consent policy (click here to review).*