ROBISON DENTAL, PC PATIENT FORMS

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

Minor Child - You may need to complete both Primary & Secondary insurance blocks for parent information
ADULTS - Complete Primary Insured
Dual Coverage? - Complete both Primary and Secondary blocks

If I do not pay the entire new balance within 30 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. 

In case of default of payment, I promise to pay any legal interest on balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account of future outstanding accounts. 

Please ask at the front desk for the periodic percentage rates and minimum charges associated with overdue/outstanding account balances.

I hereby authorize payment directly to Robison Dental, PC of the group insurance benefits otherwise payable to me. 

I understand that I am responsible for all costs of dental treatment.

I hereby authorize Robison Dental, PC to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care.

The information contained herein and the dental/medical histories are correct to the best of my knowledge.

I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health professionals by any method, including electronic transfer.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

SUBJECT: Patient Consent & Office Financial Policy

I hereby authorize Dr. Robison to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Robison to make a thorough diagnosis of my dental needs.  I also authorize Dr. Robison to perform treatment, prescribe medication, and therapy that may be deemed necessary and that has been explained to me.

I understand the use of anesthetic agents embodies a certain risk.

I understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and Dr. Robison and that I am still totally responsible for all dental fees.  These fees are due and payable at the time services are rendered and payable by cash, check, VISA, Mastercard, American Express, or Discover Card.  I also assign all insurance benefits to Dr. Robison.  Any payments received by Dr. Robison from my insurance carrier will be credited to my account, or refunded to me if I have paid the dental fees incurred.

I further understand that a billing charge of $10 will be added to any balance that is over 30 days or more old (60 days for insurance accounts).  This charge will be added to the account each billing period until the account is paid. If a check is returned to Dr. Robison for insufficient funds, closed account, etc., a $25 fee in addition to any bank charges will be assessed to the account.  In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.

I understand there will be a charge for each broken appointment of $52.00 if 48 hours notice is not given (with the exception of emergencies).

I understand that an estimate of any dental treatment required is guaranteed for only 90 days from the date the estimate is given. 

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

I request and authorize that the above-named doctor or health care provider to release the information specified below to Dr. Letha Robison. I understand that the information to be released includes information regarding the following condition (s):

AUTHORIZATION:  I certify that this request has been made voluntarily and that the information given is accurate to the best of my knowledge.  I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it.  Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event;

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

 SECTION B:  TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Y0U ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. Please see receptionist when you arrive at the office to sign an acknowledgement of receipt of this document.

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

Due to dental complications that may occur with certain cancer therapy drugs, please answer the following questions prior to your first visit: