Family Dental Care of Gainesville, PLLCDr. Matthew Bayne, DDS112 N. Denton StreetGainesville, TX 76240 Offce phone: 940-665-4211___________________________________________________________________________________________________

FINANCIAL AGREEMENT

Welcome to Family Dental Care of Gainesville! Thank you for selecting our office for your dental care. We are committed to providing excellent dental care with concern for your personal needs. The following information will acquaint you with our office financial policies and allow us to provide a high quality of service to you.

� Insurance Benefits:

We are happy to complete and submit your insurance forms on your behalf. Every effort will be made to collect the maximum benefits allowed by your insurance company. However, your insurance is a contract between you and your insurance company. We ask that you read your policy carefully.

Some or all of the services we provide may not be a covered benefit. We cannot guarantee the payments level that is quoted nor have information on benefits used in any other dental professionals office if used within your plan year. Any balances remaining after your insurance pays, are due within 15 days of billing.

� Payment:

Our policy is to collect FULL PAYMENT at the time of service. If insurance benefits apply, patient CO-PAYMENTS and DEDUCTIBLES are due at the time of service, unless other arrangements are made.

� Minor Patients:

The adult accompanying the minor (under the age of 18) is responsible for full payment of the services provided. A parent or legal guardian MUST accompany the minor unless prior arrangements have been made.

� Missed Appointments:

For the courtesy of other patients that are waiting for appointment times, please be aware that we require a 24 hour notice to change or cancel an appointment to avoid a charge.

PAYMENT OPTIONS:

We accept: VISA, MASTERCARD, DISCOVER, CASH, OR CHECK

I will assume responsibility for fees associated with any procedure done, even in the event my insurance carrier does not cover them in full or in part. I have also read the above financial policy and fully understand it.

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Date Patient Signature (Parent if under 18)

Family Dental Care of Gainesville, PLLCDr. Matthew Bayne, DDS112 N. Denton StreetGainesville, TX 76240 Office phone: 940-665-4211

ACKNOWLEDGMENT OF PRIVACY PRACTICES&

AUTHORIZATION FOR COMMUNICATION

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, underthe Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will beused to:

• Provide and coordinate my treatment among a number of health care providers who may be involved in thattreatment directly and indirectly.• Obtain payment from third-party payers for my health care services.• Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of theuses and disclosures of my protected health information. I have been given the right to review and receive a copy of suchNotice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practicesand that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry outtreatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions,but if you do agree then you are bound to abide by such restrictions.

AUTHORIZATION TO MAIL, E-MAIL, CALL OR TEXT:

I certify that I understand the privacy risks of the mail, e-mail, phone calls and text messaging. I hereby authorize a Family Dental Care of Gainesville, PLLC representative or dentist to mail, e-mail, call or text me with communications regarding by dental health, including but not limited to things such as appointment reminders, referral arrangements and follow up care. I understand that I have the right to rescind this authorization at any time by notifying Family Dental Care of Gainesville, PLLC to that effect in writing.

Patient Signature:________________________________Date:_______________________

Names of ALL patients for which this authorization applies:

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GENERAL CONSENT

I, ________________________, consent to be a patient at the above named office and agree to a radiographic and clinical exam, including a teeth cleaning. I also understand and consent to the following:

1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crown, bridge and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, andconsent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.

5. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsureabout.

6. I will pay in full any cost of treatment or insurance copayments according to the offices financial policy. I understand that even if any insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for any costs that my insurance does not cover.

In an effort to control the increasing cost of dental care, any disputes against this office shall be resolved by “binding arbitration”. By signing this agreement, the patient agrees with the office of Family Dental Care of Gainesville, PLLC that any dispute relating to dental or medical care services for any condition, including any services rendered prior to the date of this agreement was signed, and any dispute arising out of the diagnosis, treatment shall be resolved by binding arbitration bythe National Arbitration Forum, under the Code of Procedure then in effect.

Please sign that you acknowledge Family Dental Care of Gainesville, PLLC, office of Dr. Matthew Bayne's General Consent in full.

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Other minors to be included (children): __________________________ __________________________

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