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

Dental Insurance Information
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)***
If an insurance card is available please take a picture of the front and back.
Upload or drag files here
Upload or drag files here
If an insurance card is available please take a picture of the front and back.
Upload or drag files here
Upload or drag files here
The patient identified above authorizes Jack Weil D.M.D. to use or disclose protected health information in accordance with the following:

SPECIFIC AUTHORIZATIONS

I give permission to Jack Weil, D.M.D. to use my address, phone numbers, email address, and clinical records to contact me with appointment reminders, birthday cards, reminder cards, 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 persons in the office may overhear 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.

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. 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 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 feels 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 an account becomes delinquent and is subsequently sent to a collection agency, you will be responsible for any attorney’s fees which are incurred.

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 SERVICE PERFORMED.
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.