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 10% 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 10% 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

Providers: Anamaria Cabel, DDS & Jack Weil, DMD

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

For all other insurance companies, we are considered out-of-network. Payment for out-of-network plans is due at the time of service, and any reimbursement (if applicable) will be sent directly to the subscriber. We do not accept DMO plans. We are happy to help answer questions about your insurance; however, it is the responsibility of the parent/guardian to understand their coverage, benefits, and eligibility.

All insurance claims and payments are the responsibility of the parent/guardian whose name and signature appear below, regardless of subscriber status. Our office is not responsible for delayed, unfiled, or improperly filed claims by your insurance company. Once insurance payments have been received, you are responsible for any remaining balance. Recommended treatment is based on the clinical judgment of Dr. Cabel and Dr. Weil and may not be determined by insurance coverage. Balances are due upon receipt of the statement, and all outstanding balances must be paid prior to future visits.

Payment Plans & Delinquent Accounts

If a payment plan is established, balances must be paid within 90 days unless other arrangements are made. Late or missed payments may incur a 19.99% APR and/or a $10 monthly late fee. This applies to all overdue balances. If a credit card is kept on file, it may be automatically charged for any outstanding balance.

Please note: When credit cards are charged, the merchant name on your bank or card statement will appear as Capital Kids Dental.

If an account becomes delinquent and is sent to collections, you will be responsible for all related attorney’s fees and collection costs.

Specific Authorizations

I authorize Anamaria Cabel, DDS & Jack Weil, DMD to use my address, phone numbers (including cell phone numbers), email address, and clinical records to contact me regarding appointments, reminders, billing statements, and information related to treatment or oral health.

I authorize treatment to be provided in an open-bay clinical setting where other patients may be present. I understand that others may inadvertently see or overhear portions of my protected health information. A private room will be provided upon request for confidential conversations.

By signing this form, I authorize Anamaria Cabel, DDS & Jack Weil, DMD to use and disclose my protected health information as outlined above.

Right to Revoke Authorization

You may revoke this authorization in writing at any time. Revocation is not effective for services already provided or actions already taken in reliance on your previous authorization.

To revoke this authorization, submit a written request to the Privacy Official of Capital Kids Dental containing:

• Patient’s name and date of birth
• Parent/guardian name and last four digits of SS#
• A clear statement of the intent to revoke authorization
• Date of request and signature

Financial and Insurance Policy

Although we submit out-of-network claims as a courtesy, treatment recommendations are based solely on clinical needs and not insurance limitations. Coverage of procedures is determined by your insurance plan, and any non-covered services remain the responsibility of the subscriber.

Late arrivals may require rescheduling and may incur a fee. We require at least 24 hours’ notice for cancellations. Failure to cancel with sufficient notice may result in a $50.00 fee.

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.