Patient Registration Form
A detailed REGISTRATION FORM is required of all our patients. This permits us to accurately file your dental benefit claims, to contact you, and follow-up should the need arise. Please inform us of any changes to the information you initially provided.
An extensive health history is required because we are concerned with your health. Many systemic conditions/diseases effect how your treatment is planned and delivered to you. Therefore, we ask that you complete our HEALTH HISTORY FORM carefully and fully upon your first visit and keep it updated as your medical condition changes, but should be updated at least yearly.
We need to know what medications you are taking on a regular basis including over the counter medications and vitamins and herbal remedies. Please come prepared with the names and dosages of all of them!
SUGGESTION: If you take prescription medication, make a list of the medication along with the dosage to carry in your wallet. This not only helps with our forms, but also aids emergency medical personnel should the need ever arise.
All patients receive a treatment and financial consultation before treatment is initiated. We will do our best to estimate your dental benefits, if applicable, and to find other financing or payment options to help you get the dental work you need and want. If we don't address your financial needs, please ask.
Our appointments are confirmations! We have reserved that time exclusively for you. We will send text message and email reminders to help you remember. We will also give you a reminder phone call if you request.
Our office offers the following:
- Senior Citizen Courtesy
- Prepayment Courtesies (for treatment over $1000.00)
- Customer Appreciation Club (for our patients without insurance coverage)
- PLEASE NOTE: courtesies cannont be combined.
We are a Preferred Provider for, and accept all Delta, Cigna, United Concordia, Aetna and Assurant Insurance.
Financing Dentistry – Other Dental Work Financing Options:
Prosper Healthcare Lending
Prosper Healthcare Lending is the premier financing company in the healthcare industry. With over $3 Billion borrowed and over 250,000 people empowered, this is a name and a program you can trust.
Here are some of the benefits you’ll receive with a loan from Prosper Healthcare Lending:
- Immediate decisions without affecting your credit!
- Longer terms for lower monthly payments
- No collateral required
- No prepayment penalties
- Fast & easy loan inquiry process
- 100% Confidential
- 100% Confidential
CareCredit Healthcare Financing
CareCredit, the leader in patient financing, has helped more than 1 million patients get the treatment or procedures they needed and wanted. With a comprehensive range of plan options, a plan with a low monthly payments to fit comfortably into almost every budget, is available. For more information please log in to www.carecredit.com
Payment is expected at the time of service. For your convenience, we accept cash or check, as well as Visa, Mastercard, American Express, and Discover.
Dental insurance is a misnomer. It is really NOT insurance, but a benefit. An employer who provides dental benefits collaborates with the provider of these benefits to determine which services are to be covered. By choosing to exclude higher cost services and capping the benefit, the employer controls the premiums. This is obviously not in the best interest of the employee. However, some coverage is better than none.
Dental benefits have not been adjusted for inflation! The typical $1000.00 yearly dental benefit began in 1967. Had this benefit kept pace with inflation, it would be approaching $10,000.00 yearly. Dental benefits, therefore, can not be expected to cover major dental services. The dental benefit is more of a maintenance benefit.
At Southern Boulevard Dental Center, we attempt to maximize your dental benefits, but we cannot allow the lack of full coverage to determine the proper treatment of your dental needs. We will file the claims for benefit reimbursement, but please be aware that limiting your treatment to what is covered by your benefits is clearly not in your best interest.
We are contracted preferred providers for, and accept Delta Dental, Aetna, United Concordia, Assurant and Cigna insurance. We will accept insurance payments from all other insurance companies, except Medicaid, Medicare, or Centennial Care, but we are not contracted providers for them. We have many patients with other insurance who choose to come to our office and pay a small amount extra for the quality service we give. We will do our best to help you to determine what your benefits will cover, but because insurance is a contract between you and your insurance company, the best that we can give you is a good estimate. We will file insurance for you, but ultimately you are responsible for the payment of services rendered.
Our primary goal is to provide you with the quality care you need or desire. In our office, we strive to maximize your insurance benefits and make any remaining balance easily affordable. Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We are sensitive to your financial circumstances and we will do everything possible to help you achieve the best oral health.
If you have insurance, we will assist you with determining your insurance benefit eligibility before treatment, so that you will have an estimate of what your out of pocket expenses will be. We are happy to submit the claims necessary to see that you receive the full benefits of your insurance coverage; however we cannot guarantee any estimated coverage. If there are any complications, we will assist you with any information you may need. Ultimately, however, you are responsible for payment of the obligation.
For your convenience, we accept the following forms of payment: Cash, Check, Visa and MasterCard. We offer a discount for treatment plans of over $1,000 paid in full in advance: 10% in cash or 5% with credit card. We offer a Customer Appreciation Discount Plan for our patients without insurance. In addition, we offer Prosper Healthcare, CareCredit and other payment programs offering a range of No Interest and Extended Payment Plans.
Payment for services is due at the time services are rendered unless prior arrangements have been made. Checks that are returned to our office from your financial institution are subject to a $40.00 returned check fee. Any balance remaining on your account after 60 days will be subject to a finance charge of 1.5% (18% annually) which will be added to your balance. In the case of a default, you would also be responsible for collection costs and reasonable attorney fees as may be required to effect collection of this debt.
We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Most often, financial misunderstandings can be managed with a phone call. Please feel free to contact our wonderful office management team at any time to discuss any concerns you may have.
Rescheduling / Change in Schedule Policy
Our practice is dedicated to quality care and exceptional service. Dr. Goebbel and our awesome team of skilled professionals spend extensive amounts of time preparing for your visit. Broken and missed appointments create scheduling problems for our team as well as other patients. If you find that you must change your appointment, we require a minimum notice of 48 hours, so that we can make every effort to accommodate other patients. If proper notice is not received, a fee of $50.00 may be charged.