7215 ENGLE ROAD, FORT WAYNE, IN 46804

P: 260.434.1133 F:260.459.3399

INDIVIDUALS INVOLVED IN MY CARE

I understand that Legacy Dental is not always able to provide information regarding my care to others because

my health information is protected by law. There are times when that information can be disclosed without my

direct authorization if it is relevant to my care, such as times of emergency, if I am unconscious, or if I have a

family member or friend with me speaking to a health care professional.

However, at times it may be difficult for Legacy Dental to identify whether someone is a family member,

friend, or other individual who is involved in my care, and I may not always be able to provide that information,

such as if there is an emergency, if I cannot communicate, or for other reasons. To assist my healthcare

providers in making these decisions, I am disclosing below any individuals involved in my care that can be

contacted about or provided with information about my medical status, whereabouts, treatment instructions,

medications, or other matters relevant to my care or medical status. I understand that I am giving Legacy Dental

permission to disclose my protected health information to these individuals if and when Legacy Dental feels it

is appropriate.

NAME:_________________________ Relationship: _____________ Phone:______________

NAME:_________________________ Relationship: _____________ Phone:______________

NAME:_________________________ Relationship: _____________ Phone:______________

This authorization is in effect until revoked by me. I have the right to revoke this authorization in writing at any

time. I am signing this authorization voluntarily. No treatment, payment, or eligibility for benefits will be

affected if I do not sign this authorization.

I, ___________, agree to the above and understand that this will remain in effect until I notify Legacy Dental of

any changes in writing.

I, ___________, have received a copy of this office’s Notice of Privacy Practice, or read the copy in the office.

PATIENT NAME (LAST, FIRST, MI)

ADDRESS CITY/STATE/ZIP

DATE OF BIRTH SSN

Signature of Patient: Date:

Signature of Legal Representative

(state relationship to patient)

Date:

PAYMENTS/INSURANCE/CHANGE OF APPOINTMENT POLICY

We are committed to providing you with the best possible care. In order to achieve this goal, we need

your assistance and understanding of our payment policy.

We would like to emphasize that as dental care providers, our relationship is with you, not your

insurance carrier. We have established what we feel to be reasonable and competitive fees for our services in

this geographical area.

Occasionally insurance carriers imply that we are over charging. We feel it is important that they simply

state the amount they are willing to pay. This often places the physician in a sensitive situation that could

interfere with a patient/dentist relationship. If this reimbursement of services is too low, we suggest you contact

the insurance carrier or your employer’s plan administrator.

Provided we participate with your ‘insurance network’ your claim will be filed according to our current

contractual agreement. Please review participation for your particular insurance plan. You will be responsible

for any co-pays, deductibles and referrals when they apply.

All professional services rendered and charged are the patient’s responsibility regardless of insurance

coverage. We ask for payment of your fees at the time the service is rendered. This would include any co-

pays, deductibles or the full fee when there is no contractual agreement with your carrier. We accept cash,

check and all major credit cards for your convenience.

In an effort to continually meet this standard of care we adhere to a Change of Appointment Policy.

This policy allows other patients the chance to be scheduled into a previously occupied appointment.

All patients must provide at least 48 hours of notice prior to rescheduling or a cancellation.

Failure to give 48 hours of notice will result in a $100 cancellation fee.

This fee cannot be billed to your insurance provider and will be your direct responsibility.

We understand that illness or emergencies happen. Our team will always do our best to accommodate your

needs. Should you have any questions or concerns, please don’t hesitate to speak with our Legacy Dental

Team member.

______________________________________ _________________________________

Patient/Guardian Signature Date

______________________________________

Patient/Guardian Name