These forms will expedite your visit while in our clinic and will help us to get to know a bit more about you and how to best serve you when visiting us in person, and will only take a few minutes.
I agree to be responsible for all charges for dental services and or materials not paid by my dental plan, unless prohibited by law, or unless Purple Tooth Dental, has a contractual agreement with my plan prohibiting all or a portion of such charges to the extent permitted by law, I consent to the use and disclosure of my protected health information (PHI) to carry out payment activities in connection with any and all claims.
ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of dental benefits (if in network) otherwise payable to me, directly to: Purple Tooth Dental, 112 Woodlawn Ave. Mt. Holly, NC 28120. If my insurance is not in-network with Purple Tooth Dental, I hereby agree to be responsible for all the charges of treatment rendered no later then the day of its completion.