Form

703-255-2573 (call or text)
402 Maple Avenue West Suite B
Vienna, VA 22180
www.WeilPediatricDentistry.com

Dental Insurance Information

Do you currently have Dental Insurance?

If you answer "No" payment will due at the time of service.

Initials

If you answer "I don't Know" the information will be needed 24 hours before appointment to confirm eligibility or full payment will be due at time of service. If new and/or correct insurance info is given after the appointment, a 5% surcharge of the refund amount will be assessed if a refund is needed.

Initials

If you answer "Yes, but I don't know info at this time" the information will be needed 24 hours before appointment to confirm eligibility or payment will be due at time of service. If new and/or correct insurance info is given after the appointment, a 5% surcharge of the refund amount will be assessed if a refund is needed.

Initials

***We need your Dental Insurance information NOT your medical insurance information (they are different with most companies unless your dental is connected to your medical)***

Dental Insurance Company

Name of Subscriber/Policy Holder:

Subscriber/Policy Holder SSN:

Employer Name:

Subscriber/Policy Number:

Group Number:

Subscriber/Policy Holder Date Of Birth:

If an insurance card is available please take a picture of the front and back.

Front of Dental Insurance Card (Landscape)

Upload or drag files here

Back of Dental Insurance Card (Landscape)

Upload or drag files here

Do you have a Secondary Dental Insurance?

Secondary Dental Insurance Company

Name of Subscriber/Policy Holder for Secondary:

Secondary Subscriber/Policy Holder SSN:

Secondary Employer Name:

Secondary Subscriber/Policy Number:

Secondary Group Number:

Secondary Subscriber/Policy Holder Date Of Birth:

If an insurance card is available please take a picture of the front and back.

Front of Secondary Dental Insurance Card (Landscape)

Upload or drag files here

Back of Secondary Dental Insurance Card (Landscape)

Upload or drag files here

Number of children covered under this dental plan:

Patient First Legal Name (1)

Patient Last Legal Name (1)

Patient Date Of Birth (1)

Patient First Legal Name (2)

Patient Last Legal Name (2)

Patient Date Of Birth (2)

Patient First Legal Name (3)

Patient Last Legal Name (3)

Patient Date Of Birth (3)

Patient First Legal Name (4)

Patient Last Legal Name (4)

Patient Date Of Birth (4)

Patient First Legal Name (5)

Patient Last Legal Name (5)

Patient Date Of Birth (5)

Patient First Legal Name (6)

Patient Last Legal Name (6)

Patient Date Of Birth (6)

Patient First Legal Name (7)

Patient Last Legal Name (7)

Patient Date Of Birth (7)

Patient First Legal Name (8)

Patient Last Legal Name (8)

Patient Date Of Birth (8)

Patient First Legal Name (9)

Patient Last Legal Name (9)

Patient Date Of Birth (9)

Patient First Legal Name (10)

Patient Last Legal Name (10)

Patient Date Of Birth (10)

*ATTENTION*

Financial and Authorization Form

WE ARE IN-NETWORK PROVIDERS FOR:
CIGNA PPO, DELTA DENTAL PPO & PREMIER, METLIFE PPO, UNITED CONCORDIA PPO, & AETNA PPO ONLY

For any other insurance company, we are considered out-of-network. For all out-of-network insurances payment will be due at the time of service and reimbursement (if any) will be sent to the subscriber directly. We don’t accept any DMO Plans. We will gladly answer questions to the best of our knowledge about your plan, but it is your responsibility to know your benefits, in-network providers, and eligibility. All insurance claims and payments are always the responsibility of the Parent or Guardian of the patient whose name and signature appears below regardless if they are the subscriber of the insurance. We are not responsible for failure to file a claim or for improperly filed claims. After insurance claims have been filed and payment received, you are responsible for any remaining balance. Dr. Weil’s treatment is what he deems is in the best interest of the patient, not what is covered or not covered by your insurance plans. Balances are due upon receipt of the statement. All outstanding balances must be paid in full prior to future visits.

If a payment plan is set up, balances must be paid off within 90 days unless other arrangements are discussed. If these payments are not made in a timely manner, you may be charged an APR of 19.99% and/or a late fee of $10 per month the balance remains unaddressed. This also applies for any overdue balance. If credit card is saved on file, I understand it will be auto charged for any outstanding balance. If an account becomes delinquent and is subsequently sent to a collection agency, you will be responsible for any attorney’s fees which are incurred.

SPECIFIC AUTHORIZATIONS

I give permission to Jack Weil, D.M.D., to use my address, all phone numbers including cell phone numbers, email address, and clinical records to contact me with appointment reminders, birthday cards, reminder cards, texting, billing statements, and information about treatment alternatives or health related information.

I give Jack Weil, D.M.D., permission to treat me in an open room where other patients are also being treated. I am aware that other people in the office may overhear and/or inadvertently see some of my protected health information during care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations.

By signing this form, you are giving Jack Weil, D.M.D., permission to use and disclose your protected health information in accordance with the directive listed above.

RIGHT TO REVOKE AUTHORIZATION

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization.

You may revoke the AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Jack Weil, D.M.D. The written notice must contain the following information:

• Patient name, date of birth, parent/guardian name and SS#
• A clear statement of your intent to revoke the AUTHORIZATION
• The date of your request, and your signature

Financial and Insurance Policy

While our office is more than willing to submit insurance claims on your behalf if we are out-of-network, we are doing so as a courtesy.

Treatment is not determined by your dental insurance plan; it is determined by what Dr. Weil deems necessary at the time of visit. Procedures covered or not covered are the responsibility of the subscriber/member.

Late arrival to scheduled appointments may result in cancellation of the appointment and may be subject to a fee.

We have a 24-hour cancellation policy for appointments. Failure to cancel an appointment 24 hours in advance may result in a charge of $50.00.

I UNDERSTAND AND AGREE TO THE ABOVE STATED INFORMATION AND THAT I AM ULTIMATLEY FINANCIALLY RESPONSIBLE FOR THE SERVICE PERFORMED.

Parent/Guardian/Patient First Name

Parent/Guardian/Patient Last Name

Best Family Cell Phone Number

Best Family Email

Patient/Guardian/Patient Signature

Date

This communication is secure and encrypted for your protection. Once submitted it is sent directly to the office. It may contain protected health information (PHI) that is legally protected from inappropriate disclosure by Privacy Standards of Health Insurance Portability and Accountability (HIPAA) and relevant Virginia Laws.