PATIENT RESPONSIBILITY AGREEMENT

My signature below confirms that I fully understand I am financially responsible for any and all charges related to my care at Hillside Dental Care. Whether or not I have insurance or are self-pay, payment of my account balance is due within thirty (30) days of receipt of my billing statement.
Cash, personal checks, Mastercard, Visa, American Express, Discover, Care Credit and other forms of third-party financing are all acceptable forms of payment. All payments are required at the time of service.
Any returned checks are subject to a $55.00 processing fee and must be resolved prior to scheduling future appointments. Only cash, credit cards or Care Credit will be accepted after a second occurrence of a returned check. I understand if my balance remains unpaid after 30 days, I will be responsible for any collection fees and/or legal/court fees associated with non-payment, including interest charges of 1.5% per month or at the maximum rate permitted by law, which accrues on my outstanding balance.

APPOINTMENTS

I understand that my appointments are reserved exclusively for me, and actual costs are associated with this time. It is my responsibility to provide a minimum of two business days’ notice if I am unable to keep my appointment or need to reschedule. Failure to do so may result in a $100 late cancelation fee.
I consent to the use of anesthetics, sedatives, photography, and x-rays if needed. If a testimonial is given by me, I consent to the use of my image and statements, and all audio, video and photographic recordings of my image and statements in any promotional or educational material relating to Hillside Dental Care.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

My signature below confirms my consent that Hillside Dental Care may use and disclose Protected Health Information (PHI) about me to provide and conduct Treatment, Payment, and Healthcare Operations (TPO). I may obtain a written copy of Hillside Dental Care’s Notice of Privacy Practices for a more complete description of such use and disclosures by forwarding a written request to Dr. Frank Wolf 7241 N. Thornydale Rd. Tucson, Arizona 85741. Hillside Dental Care reserves the right to revise its Notice of Privacy Practices from time to time.
Hillside Dental Care may call my home or other designated location and leave a voice message, text message, or email in reference to any items that assist the practice in conducting TPO, including but not limited to appointment reminders, insurance items, account statements and any call pertaining to my clinical care.
By signing this form, I am consenting to Hillside Dental Care’s use and disclosure of my PHI to
conduct TPO. I may revoke my consent in writing except to the extent that the practice has
already made disclosures in reliance upon my prior consent. If I choose not to sign this consent form, Hillside Dental Care may decline to provide dental services to me.
I have had the opportunity to read this Patient Responsibility Agreement in its entirety and have had the opportunity to ask questions regarding the details of this Agreement. Any questions have been answered to my satisfaction and I have received a copy of this Agreement if requested by me. I consent and agree to the aforementioned terms of this Agreement.

PATIENTS WITH INSURANCE

Hillside Dental Care will act as an advocate on my behalf and will call my insurance company and obtain a breakdown of my benefits and provide an estimate of coverage if requested by me. Hillside Dental Care will also help me realize the full benefits of my coverage by submitting all my claim forms and any additional information required.
My insurance contract is a relationship that is between me, my employer and my insurance company, and Hillside Dental Care is the provider of dental services only. It is my responsibility to know and understand what type of dental plan I have and to know my insurance coverage benefits and policy limitations. Any dollar amount quoted related to a treatment plan that Hillside Dental Care offers to me is an estimate only of what my insurance may cover, and it is not a guarantee. 
My treatment plan may change for a variety of unforeseen reasons and Hillside Dental Care has no control over contractual downgrades of services by my insurance company. Hillside Dental Care makes no guarantee of coverage or payments made by my insurance company and assumes no responsibility regarding my insurance benefits or coverage.
Because of Hillside Dental Care’s high standards-of-care, their use of the best quality materials, and their commitment to honoring the Doctor-Patient relationship, they do not allow insurance companies to dictate treatment, the services provided, or the manner and materials that may be used for my care.
I have the option of paying for my treatment in full at the time of service and being reimbursed by my insurance company; or paying my estimated co-payment at the time of service and keeping a credit card on file to pay for any outstanding balance that my insurance company does not cover.