Online Form Submission

To submit online, please fill out this form and then click SUBMIT

Email Address *
Date Completed *
Your Name *
Address *
City *
State *
ZIP *
Date of Birth *
Preferred Contact Phone Number *
Home Phone Number
May we call you at work? Yes No
Work Phone Number
Mobile Phone Number
Emergency Contact Information (name, address, phone number & relationship)
Occupation
Employer
Employer Address
Employer City
Employer State
Employer ZIP
____________________________________________________

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
(HIPAA)
TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry our treatment, payment activities, and health care operations. WE WILL NOT RELEASE ANY OF YOUR HEALTH INFORMATION TO MARKETORS OR SOLICITORS.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign the Consent. Our Notice provides a description of out treatment, payment activities, and health care operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available from the Contact Person. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting our office manager at 321-259-9429 or at the office located at 2113 Sarno Road, Melbourne, Florida.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will NOT affect any action we took in reliance of the Onsent before we receive your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent.
I have had full opportunity to read and consider the contents of this Consent form and the Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. I also agree that my protected health information may also be disclosed to the following person(s) as listed below.
May we share your health information? * Yes No
If yes, with whom?
Signature (HIPPA) *
Type your name here.
________________________

Insurance Information

OFFICE INSURANCE POLICY AND ASSIGNMENT OF BENEFITS - PLEASE READ CAREFULLY
I understand that an insurance policy is not a guarantee of payment. While every effort will be made to insure the accuracy of my insurance plan benefits, I understand that the office estimate of my insurance benefits is NOT a guarantee of accuracy and in fact will not be exact. I understand that a pre-determination of benefits will result in the most accurate estimate of my insurance plan benefits, however even a pre-determination of benefits is NOT a guarantee of payment by the insurance company.
I understand that the office will file for a pre-determination of benefits only on estimated claims exceeding $500.00 and that a pre-determination of benefits may take in excess of six weeks to be processed by my insurance company. I understand that the filing of my insurance claim is a courtesy extended by the office and that the office is not an agent for my insurance company, and has no control or influence over them, their policies or their payments.
I understand that my insurance company has not examined me and does not know my dental condition and dental needs. I understand that my insurance company may deny payment or change the treatment to a lesser cost treatment option and that this is done strictly for the economic benefit of my insurance company and not to my personal benefit. I understand that my insurance company may not pay for certain materials or procedures and that this is done for the economic benefit of my insurance company and not for my benefit. I understand that Dr. Brown will recommend and use materials and treatment procedures that are in my best interest and not based upon my insurance company\'s payment considerations.
I agree to be responsible for the full amount of the charges for my treatment. If I elect to have payment (if any) made to Dr. Brown by my insurance company, this will be applied towards the full amount of charges for my treatment.
I hereby authorize the release of any information pertaining to my treatment and claim to the above insurance companies and their representatives. I authorize the release of my information to the above insurance companies by electronic submission through national clearing houses that are governed by the HIPPA privacy act.
I hereby authorize payment to be made directly to Dr. Clark Brown of the group insurance benefits otherwise payable to me.
Signature (Insurance Information) *
Type your name here.
Dental Insurance Information
PRIMARY Insurance Company Name
Primary
Insured's Name
Primary
Insured's Relationship to Patient
Primary
Group Number
Primary
Policy ID Number
Primary
Insured's Date of Birth
Primary
Insurance Company Phone Number
Primary
Insured's Employer
Primary
Insured's Employer Phone Number
Primary
_________________________________
SECONDARY Insurance Company Name (if any)
Secondary
Insured's Name
Secondary
Insured's Relationship to Patient
Secondary
Group Number
Secondary
Policy ID Number
Secondary
Insured's Date of Birth
Secondary
Insurance Company Phone Number
Secondary
Insured's Employer
Secondary
Insured's Employer Phone Number
Secondary
_______________________________

Medical Insurance Information

(Note that some diagnostic procedures may, under certain circumstances, be eligible for coverage under medical insurance. If so, they will be billed to your medical insurance company.)
MEDICAL Insurance Company Name (if any)
Medical
Insured's Name
Medical
Insured's Relationship to Patient
Medical
Group Number
Medical
Policy ID Number
Medical
Insured's Date of Birth
Medical
Insurance Company Phone Number
Medical
Insured's Employer
Medical
____________________________

FINANCIAL POLICY & AGREEMENT
Thank you for allowing us to be your dental care provider. We are committed to providing the highest quality of dental care to all of our patients. The prompt payment of your treatment fees allows us to continue providing the highest quality of care. In the pursuit of these goals, we have established the following financial policy:
ESTIMATES We will give you a cost estimate before treatment is rendered. We will try to insure that the cost estimate is complete and accurate, however there are circumstances when it becomes impossible to know exactly what treatment needs to be performed. Sometimes the dental condition requires less treatment, in which case your treatment fees will be less than estimated. Other times, the dental condition requires more treatment than initially anticipated, in which case your treatment fees will be more than estimated. If more treatment is required than initially estimated, you will be informed of the treatment required and fees before the additional treatment is performed.
PAYMENT DUE Full payment of the fees are due at the time of service. We accept cash, check (drawn on a local bank), VISA, Mastercard and Discover. Treatment which requires more than two hours of appointment time will require payment in full five business days prior to the appointment. Appointments will automatically be cancelled if payment is not received.
PAYMENT PLANS Payment plans are available only through CareCredit. Interest free plans are available to qualified individuals. CareCredit and NOT this office determines who may qualify and the amount of credit available.
BROKEN APPOINTMENTS We require 24 hours notice to cancel or reschedule an appointment. There will be a per-hour fee assessed for failure to provide 24 hours notice to cancel or reschedule an appointment.
AFTER-HOUR EMERGENCY CARE We provide after-hours emergency care for established patients only. There will be a fee charged for after-hours care.
INSURANCE If we do not participate in your dental insurance plan, you still may receive benefits payable by your dental insurance company. You will be required to pay for treatment in full. We will file your insurance claim for you, assigning benefits directly to you. Your insurance company will reimburse you according to their own fee schedules and restrictions. We regularly monitor the usual and customary fees for our area and insure that we are within this range. The insurance company\'s "usual and customary fees" are NOT based upon the current fees being charged in a particular area.
If we are a participating provider for your dental insurance, we will file your insurance claim for you. We will estimate your insurance benefit and you will be required to pay the estimated balance at the time of treatment. Since the insurance benefit is an estimate only, you will be required to pay any amount still due after your insurance company pays on the claim. If there is a credit on your account after the insurance payment, this amount will be refunded to you or remain as a credit on your account for future treatment, as your choice. The OFFICE INSURANCE POLICY AND ASSIGNMENT OF BENEFITS is made a part of this Financial Policy & Agreement.
COLLECTION OF PAST DUE ACCOUNTS Accounts that are not paid within 30 days according to this Financial Policy & Agreement are charged 18% interest, or the maximum legal allowable interest, from the date of the bill. This Agreement is governed by and construed under the laws of the State of Florida. Jurisdiction and venue of any legal or equitable action shall lie exclusively within Brevard County, Florida. In the event legal or other collection action becomes necessary, the prevailing party shall be entitled to recover all costs and fees, including attorney fees, incurred in any such action.
RETURNED CHECKS Any checks returned due to insufficient funds must be paid within five business days and will incur a $25 returned check fee. Returned checks not paid in full (including the returned check fee) within five days will incur a 1.5% per month interest charge and the account may be turned over for collection. Any checks returned for being written on a closed account will be forwarded to the State Attorney and the account immediately sent to collection.
I have read, understand, and agree to abide by this Financial Policy & Agreement.
Signature (Financial Policy & Agreement) *
Type your name here.

Implant Dentistry of Florida

Cosmetic, Implant & General Dentistry