Dothan Dentist

New Patient Form

Acknowledgement of receipt
of notice of privacy practices

  • Date
  • [Date]

I, _________________________________________________________, have received a copy of Dothan Cosmetic Dentistry NOTICE OF PRIVACY PRACTICES. I acknowledge thatI understand the use of my private information for treatment and insurance purposes.I give my consent for Dothan Cosmetic Dentistry to file my information for me

  • Patient Signature:
  • [Signature]
  • Witness Signature:
  • [Signature1]

Statement Of Financial Responsibility


Assignment of Insurance Benefits I hereby authorize payment directly to Dothan Cosmetic Dentistryof all medical benefits otherwise payable to me or on my behalf for the treatment(s) performed and/or service(s) rendered at Dothan Cosmetic Dentistry. I understand any payment sent directly to me shall then be forwarded to Dothan Cosmetic Dentistry. I understand any unpaid deductibles, co-pays, or co-insurance amounts not payable by my insurance are my responsibility regardless of any pending insurance amounts. These amounts due from me are due on the date of service. This assignment of benefits is valid for insurance companies and programs.

Authorization of Release of Information I authorize Dothan Cosmetic Dentistryto release any and all medical information concerning the treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistryas may be required by my insurance company in order to process payment of my claim(s)

Charges I understand that standard charges have been established for all services at Dothan Cosmetic Dentistry. I further understand that the fee(s) for my treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistrywill be billed to my insurance company. If any additional treatment(s) and/or service(s) are deemed necessary by my physician, and performed today, those treatment(s) and/or service(s) will be billed to my insurance company as well.

Credit Policy Dothan Cosmetic Dentistrywill file the appropriate claim forms to my insurance carrier. I will be notified when the final action (payment, denial, etc.) by my insurance carrier has been received. I understand that if myaccount becomes delinquent it will be placed with Prim and Mendheim LLC. Further, I agree to the following terms regarding any outstanding balance that I owe: (1) I will incur interest at the rate of 1 & ½ percent per month (18% per annum); (2) I agree and hereby consent that I will be responsible for reasonable collection costs, attorney’s fees, and any court costs that are incurred by Dothan Cosmetic Dentistryin the collection of same, whether such outstanding balance is satisfied prior to, after initiation of a lawsuit, or after a judgment has been issued in a lawsuit; and (3) I agree and hereby consent that any lawsuit and/or legal proceeding surrounding the outstanding balance and debt, and fees and costs thereon, shall be initiated and litigated in the court of appropriate jurisdiction of Houston County, Alabama, and I hereby waive any and all defenses and/or objections to said jurisdiction. I agree that if I have listed a cell phone number as a point of contact that I can be called at that number regarding my balance. Additionally, I agree to waive any and all state and/or federal personal property exemptions, wage exemptions, and/or homestead exemptions of my state of residence and/or state of operation in the event of judgment, levy, and/or garnishment. Further, if I reside in Floridaor GeorgiaI agree to waive my rights to any exemption that would prohibit a wage garnishment should same become necessary to secure payment of any outstanding balance.

I, ________________________________________, have read and understand the terms of this policy statement.

  • [Signature]
  • [Date]
  • Patient’s Signature (Parent or Guardian if Minor)
  • Date
  • [Signature1]
  • [Date]
  • Signature of Insured if other than Patient
  • Date