Welcome to First State Dental
First State Dental is accepting new patients. Whether you need to have your teeth cleaned or you would like a total smile makeover, you have come to the right dental practice. Our primary goal is to create and maintain the dental health of our patients. We are focused on your dental needs and desire to create a beautiful healthy smile.
New Patient Forms
The following patient registration forms can be downloaded to your computer, printed, and completed in the privacy of your home. In order to provide a complete and comprehensive examination, consultation, and treatment plan, it is important to review all your medical information, including medications you take.
Please be prepared to provide this information to our office along with your current dental insurance information so that we may use our expertise to assist you in maximizing your dental benefits. Below is a link to our patient registration forms. If you have any questions about these forms, our staff will assist you with your questions on the day of your visit.
Patient Registration and Dental History Forms- HIPAA - Acknowledgment of Receipt of Notice of Privacy Practices
- HIPAA - Notice of Privacy Practices
- Financial Responsibility Policy
- Transfer of Records Release
Effective May 1, 2016
First State Dental designates Karen Coho as:The Privacy Official, responsible for developing and implementing the dental practice’s privacy policies and procedures, and as the person responsible for: receiving complaints, providing further information about the Notice of Privacy Practices (for example, to patients, staff, etc.), and receiving and processing:requests for access, accountings of disclosures, and requests for amendment.
Payment
We accept Cash, Check, Visa, Master Card, Discover, Financing, and Care Credit.
Financing
Care Credit is a health care credit card. Care Credit applications can be made through our office for 1) interest-free payment plans up to 12 months and 2) low interest payment plans of 24 to 60 months. See: Care Credit Application
Insurance
We accept all insurance. First State Dental accepts some network providers. Please check with our administrator to confirm services.
Financial Responsibility Policy
As a result of the many different and confusing insurance company reimbursement policies, it is necessary to have an easily understood financial responsibility policy.
- It is important for you to provide the office with complete insurance information for all carriers with whom you are insured at the time of service. At each office visit we need you to show us your insurance card to insure that your current insurance information is on file.
- As a service to our patients, we will submit your insurance claim to your primary insurance company. Our office will provide the insurance company with all the information necessary to help you receive maximum benefit from your insurance company. However, it is the patient’s responsibility to know the insurance coverage and benefits limit of their particular policy.
- If a claim is denied, we will research why the rejection occurred and either resubmit to insurance or bill you the appropriate balance. If the claim is denied a second time, the appropriate balance immediately becomes the responsibility of the patient and should be paid to us directly. You may contact your insurance company for reimbursement.
- If the patient has coverage with a second insurance company, we will submit all secondary claims directly to that insurance company along with a copy of the explanation of benefits from the primary insurance. Benefits from the secondary coverage will be paid directly to the patient.
- Insurance is a patient’s benefit designed to assist the patient in their financial obligation to the office of First State Dental, P.A.. The patient is the one receiving the dental service and therefore is ultimately responsible for all charges on the account regardless of any insurance coverage. This applies to everyone in the family who is treated in the office of First State Dental, P.A..
- The office will collect the patient’s deductible and the estimated balance after the primary insurance payment at the time of service. After the primary insurance payment is received, the patient will be billed for any difference between the anticipated insurance payment and the actual insurance payment. If the insurance payment is greater than the estimation, we will either refund the amount to the patient or leave the credit balance on the patient’s account to be applied toward future treatment.
- In the event that the patient does not have insurance coverage, charges for services are due and payable at the time services are rendered, unless a signed financial agreement has been approved. I am also responsible for any insurance claims not paid within 60 days of service.
- Medicaid Insurance covers children up to 21 years of age and does not cover adults. For more information please see: http://www.cms.gov/MedicaidDentalCoverage/
- Medicare has specific eligibility requirements. For more information about eligibility, please see http://www.cms.gov/MedicareDentalCoverage/