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«WELCOME TO OMNI DENTAL GROUP We are dedicated to providing the best possible care and service to you and to helping you maximize your insurance ...»

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We are dedicated to providing the best possible care and service to you and to helping you maximize your insurance

benefits. We need your understanding of your right to privacy, our financial policy, assignment of insurance benefits, and

your responsibility in maintaining your oral health to achieve that goal. Please read the following carefully. If you have

any questions, please ask any Front Desk Associate or contact our Operations Manager.


I authorize the Doctor to take X-rays, study models, photography, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis. I further authorize and consent that the doctor may choose and employ such assistance as he/she deems fit while making a diagnosis.


After your initial examination we will discuss your oral health and recommended treatment plan with you. We will offer you treatment options where possible and plan treatment to address your most urgent needs first. In some cases, it is necessary to schedule urgent procedures prior to routine cleanings; otherwise, your routine cleaning will be scheduled at the next available appointment. Once your treatment is complete, we will monitor your general dental health at your Texas State Board required yearly examinations that will coincide with cleaning appointments whenever possible.

It is your sole responsibility to maintain your oral health. We will assist you in any way possible to facilitate your treatment.

However, if you do not comply with the planned and recommended treatment or otherwise fail to maintain your oral health, we will be unable to retain you as a patient in our practice.


Omni Dental Group does not see patients under the age of eight (8). An adult parent or guardian must accompany all minor patients (under 18 years of age) and must remain on premises, outside the operatory, throughout the appointment.

The parent or guardian accompanying the minor patient is legally responsible for any payments due at that appointment.


Omni Dental Group cannot provide child care during appointments and, as provided by state regulations, children cannot accompany an adult into the operatory. Please make arrangements for your children’s care accordingly.


Payment for services is due at the time services are rendered. We accept cash, personal checks, Visa, MasterCard, Discover, and American Express. You may also qualify for interest-free loans available through a third party lender upon credit approval. See www.carecredit.com for more information on these loans.

A 1 ½% finance charge (18% annually) will be added to any balance over 60 days. In the event of default, you promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this debt.

I understand there is a $50 FEE FOR ANY MISSED OR BROKEN APPOINTMENTS WITHOUT ONE BUSINESS DAY PRIOR NOTICE. I also understand that the cancellation of a scheduled appointment with the hygienist may result in having to miss a regular three, four or six month appointment.

All medical/dental records and X-rays are the property of this office. Any costs to transfer to another practitioner will incur a duplication fee (see Procedures and Fees…Records, Form 13-A-2005).

In the event of a returned check (NSF item) an additional amount of $30 (NSF fee) will be charged. Payment of the amount of the NSF item plus $30 NSF fee MUST be paid within 24 hours by cash, cashier’s check, or money order.

In the event of default on any balance due, for any reason, the patient (or financially responsible party) will be accountable for any and all amounts due, finance charges, collection agency fees, attorney fees, and court costs.

Patient Policy Form 2A-2AaYOUR INSURANCE

Omni Dental Group has arranged to accept many insurances and dental health plans (assignment of benefits). We must emphasize that our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy we extend our patients, all charges are your responsibility at the time of service.

Claims are filed for plans classified as “indemnity”, “fileable”, or “PPO”. Those plans require you to pay the co-payment, deductibles and/or coinsurance at the time of service. We will file claims to all insurances for which we have an agreement. Patients with indemnity/fileable/PPO insurance are required to put a credit card on file. Please read and sign the “Easy Pay Consent” form if you have as “indemnity”, “fileable”, or “PPO” insurance.

A DMO or DHMO dental plan does not require that a claim be filed. DMO or DHMO dental plans have specific fee schedules that determine your cost of services and any co-payment fees.

If your insurance cannot be verified prior to your appointment, you will be responsible for all charges of the appointment.

Utmost effort will be made to notify you of any such circumstances. Patients will be given a receipt for reimbursement from their carrier in circumstances where insurance cannot be verified.

If we do not have an agreement with your insurance carrier, we will provide you with a receipt with all the necessary information for you to file a claim. We do not provide the claim forms. Your insurance company should send the benefit payment directly to you. Consequently, the charges for your care and treatment are due at the time of service.

We do not file SECONDARY insurance plans. It is the insured’s responsibility to file any secondary coverage. The patient is responsible for the co-pay assigned by the primary insurance and must file their own secondary benefits.

In the event your dental insurance or plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. If you disagree with the insurer’s determination, you must contact your insurance company to resolve the dispute. Disputed charges shall not be adjusted on the Omni Dental Group account. The patient is responsible for all charges and any applicable finance charges.


Your insurance may contain clauses that affect the amounts paid by your insurance. Omni Dental will notify you of such clauses whenever possible; however it is your responsibility, not Omni Dental Group’s, to be aware of these clauses for your particular insurance and the effect on the amounts due. For example, an alternate benefit clause states that your insurance will only pay the cost for an amalgam filling, not a composite filling. Omni Dental Group does not do amalgam fillings. Your responsibility for charges in this case would be the cost of the composite filling minus the cost the insurance will pay for an amalgam filling and your co-pay. You are responsible for the remaining difference.

Please initial each statement and sign below as acknowledgement and acceptance of these policies.

I have read and understand the Patient Privacy Notice (HIPPA Notice) for the Omni Dental Group.

I agree to consent to services as recommended by the Doctor.

I understand it is my responsibility to comply with the recommended treatment plan and to maintain my oral health. Failure to follow the recommended treatment plan may result in dismissal as a patient.

I have read and understand the financial policies of the practice and agree to be bound by the terms.

I have read and understand the insurance information provided to me and acknowledge that specialized clauses may change the amount paid by my insurance and increase the amounts I owe..

I certify that all information I provide is true and correct to the best of my knowledge.

I understand it is my responsibility to notify Omni Dental Group of any changes in pertinent information.

I understand any of these policies may be amended by the practice from time to time.

–  –  –


We collect nonpublic personal information about you or your family when you contact us to make a dental appointment. We require a copy of your insurance card and your drivers’ license and/or photo identification. This personal information may include your name, address, telephone number, date of birth, Social Security Number, and your employer information. We ask that you complete a comprehensive health history form for your personal record, and we require verification of your dental insurance for your specific plan coverage for you and all dependants.


The personal and health information we obtain and store is used to effectively administrate your insurance benefits and to protect your health needs. Upon arrival you will sign first initial and last name on our sign in sheet, part of your name may be called if you are needed at the front desk or if you are being taken to the treatment area. Your personal health information may be discussed with your physician or another healthcare provider. Your personal information may be requested by your insurance company to provide them information to properly file a claim. A laboratory may require some of your personal information, however, that is usually limited in nature. Your treating dentist may discuss aspects of your case with one of his/her colleagues or information may be given to a specialist in order to provide treatment. The information you have provided to us may be used in the confirmation of appointments including messages left on answering machines and/or voice mail.


We restrict access to your personal and health information to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal and health information.


Omni Dental Group occasionally reviews its privacy policy and reserves the right to amend it. Should our privacy practices change, we will post a copy of the revised Notice in our waiting area that indicates the date of the amended Notice. You may request and obtain a copy of our Notice of Privacy Practices anytime you visit our office.

I have read and understand the above Privacy Notice for the Omni Dental Group.

–  –  –

Omni Dental’s business is to provide you the best dental care possible. Our dentists are here to do dentistry. They are not in the insurance business. However, they accept the risk of taking your insurance as a courtesy to help you. Omni Dental Group cannot be responsible for benefits limitations, gaps in coverage, nonpayment by the insurance company or other matters which result in cost to you. Those details are entirely between you and your insurance company. Your dental insurance policy is a contract between you and the insurance company; therefore, you are responsible for the benefits, limits, and omissions of that insurance contract.


Many people believe medical and dental insurance are similar, but, in fact, they are nearly opposite. Simply put, medical insurance covers procedures for the whole body and the benefit amounts can be in the millions of dollars.

Dental insurance only covers the oral cavity. Dental insurance benefits generally do not exceed $3,000 per year.

Your dental insurance is like a “coupon” you receive as part of the contract between your insurance and yourself (if self-insured) or your employer. Your “coupon” may be for a PPO plan which provides for your insurance company to pay a portion of your charges, or a managed care plan which negotiates reduced fees with the dentist and does not pay any portion of your charges. [see “What is the Difference between a PPO and a Managed Care Plan?”] There may be conditions in which your “coupon” only pays for certain services. This is a condition applied by the insurance company, not your dentist. When your “coupon” does not pay for a service, the fee will be your responsibility.

 Coverage, maximum benefits, deductibles, co-pays, and benefit limitations are determined by each insurance company and filed with the Department of Insurance, NOT your dentist.

 Your dentist has no control or influence on how much dental insurance pays or what procedures are covered.

 No dental insurance guarantees payment. Having insurance does not mean the insurance will pay.

Patients often ask ‘why doesn’t my dental insurance cover this like my medical insurance does?’ Most medical procedures are paid by the insurance, but most dental procedures are paid by the patient. This is due mostly to the benefit maximums. Medical insurance may provide for millions of dollars in benefits. PPO dental insurance only provides a few thousand dollars (possibly less), and any charges over the maximum are paid by the patient. Patients on managed dental plans pay all fees out-of-pocket because managed care insurance provides the buying power of the insurance company to get negotiated fees. Without a managed care plan you would pay closer to three times the negotiated fees.


A PPO, annuity, or indemnity insurance (also known as fileable, bundled plans) pays a percentage of your dental costs. You will pay deductibles, co-pays, and costs of procedures not covered by your plan. You will also pay for costs over your maximum benefits at the usual and customary fees.

DHMO, DMO, discount dental plans, also known as managed care plans, do not file claims. When you pay your premium for these plans, you are paying for access to fees negotiated on your behalf by the insurance company.

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