Patient Information - Lance D. Bailey, DDS

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Whom may we thank for referring you to our practice?

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Financial Policies

Thank you for choosing us as your dental care provider.  We are committed to your treatment being successful and to providing the highest quality dental services at a reasonable fee.  Please understand that payment of your bill is necessary in order for us to provide treatment.

Patients with Dental Insurance
As a courtesy to our patients, we prepare and process all insurance forms.  However, having insurance does not release the patient from financial responsibility. 
Our expectations of you as the owner of the policy are as follows:
	•	Estimated patient portions must be paid at the time of service.  This may include co-payments, deductibles, co-insurance and/or non-covered procedures.
	•	You are responsible for educating yourself about the details of your policy which includes deductibles, yearly maximums, and policy exclusions.
	•	If the insurance company does not pay our office within 60 days, it is your responsibility to pay using one of the payment methods listed below.  The insurance policy belongs to you and we have no leverage to obtain payment. 
Patients without Dental Insurance
If there is no insurance coverage, full payment is due at the time of service with one of the payment options listed below.

Payment Options
For your convenience, you may choose any of the following methods of payment:
	•	Cash
	•	Personal Check
	•	Visa, MasterCard, Discover, American Express, Debit

Minor Patients
The parent, guardian or adult accompanying and signing all forms for a minor will be responsible for full payment.  Parents or guardians must be present to authorize all dental treatment to minors.

Financial Agreement
I understand that I am financially responsible for all charges incurred by my dependents, or myself whether or not covered by insurance.  I hereby authorize the office of Dr. Lance D. Bailey to use the following signature for proof of signature on insurance claim forms for assignment of insurance payment and release of information.  I agree to pay Dr. Lance D. Bailey for professional services rendered to me at the time of service.  IF my insurance  pays less than estimated, I agree to pay any remaining balance within 30 (thirty) days of billing.  A $10.00 late fee will be charged to my account for each month a payment is not received.  I expressly agree to pay all costs of collection agency fees assess at up to 50% of the total amount due, and all court costs and attorney fees, if these terms are not met.

I grant my permission to you and your assignee to telephone me at home or at my workplace to discuss matters related to this form.  I also agree to allow this office to leave messages concerning appointments and/or results on my answering machine or with a family member.

Failed Appointments
After 2 missed appointments, you will be charged a $75 fee and/or be dismissed from our office.

This agreement superseded all prior agreements signed, including any and all mediation or mediation/arbitration agreements.  I acknowledge that any prior mediation or mediation/arbitration agreements signed previously related to financial arrangements or quality of care are null and void.

Available Payment Options:

	•	Cash, Check, Visa, MasterCard, American Express or Discover Card, Debit Card
	•	We offer a 10% discount to patients who DO NOT have insurance and pay for services using cash or check on DAY OF SERVICE.  We offer 5% to those who prefer to use a credit card.

Please note:

This office requires payment the day of service.  We accept payment in thirds for treatments over $350, through automatic with drawl, debit or credit card.  First payment must be made on the day of treatment, second payment must be made in 30 days, third payment must be made in 60 days. 

A $10 late fee will be charged to your account each month a payment is not received.  

For patients with dental insurance we will work with your insurance carrier to maximize your benefit and directly bill them for reimbursement for  your  treatment.*

The treatment plan is an ESTIMATE ONLY.  Your dental plan may include limitations and exclusions that will apply.  If a discrepancy occurs, YOU ARE RESPONSIBLE FOR ANY REMAINING BALANCE not paid by your insurance carrier.  Discrepancies may occur due to the following: Yearly Maximums, Deductibles, Waiting Periods, Limitations and Exclusions.  This estimate is only good for 90 days.

Our fee for returned checks is $30.00.

If you have any questions, please ask.  We are here to help you with your dental concerns.

*If we do not receive payment from your insurance carrier within 60 days, you will be responsible for the fees and collection of your benefits directly from your insurance carrier.

Signature of Patient or Responsible Party

Today’s Date:

Consent To Proceed:

LANCE D. BAILEY DDS
5685 South 1475 East, STE 1A
South Ogden, UT 84403
801-475-8000
CONSENT TO PROCEED
I authorize Lance Bailey, DDS and/or such associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.
I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness.  I understand that occasionally needles break and may require surgical retrieval.  Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation.
I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment.  Dental materials and medications may trigger allergic or sensitivity reactions.
After lengthy appointments, jaw muscles may also be sore or tender.  Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder.  Gums and surrounding tissues may also be sensitive or painful during and/or after treatment.  Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures.  In some cases, sutures or additional treatment may be required. 
I understand that as part of dental treatment, items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed.  This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require brochoscopy or other procedures to ensure safe removal.
I understand the need to disclose to Dr. Bailey any prescription drugs that are currently being taken or that have been taken in the past.  I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva, or Actonel, may result in complications of non -healing of the jaw bones following oral surgery or tooth extractions.
I do voluntarily assume any and all reasonable medical/dental risks including the risk of substantial and serious harm, if any, which may be associated with standard dental preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward.  I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.

Patient Name:

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Signature (Patient Legal Guardian, or Authorized Agent of Patient):

Today’s Date

Signature of Witness