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APPOINTMENT INTENTIONS FORM

REQUEST TO CANCEL DENTAL APPOINTMENTS

United Concordia Dental - CONCORDIA ADVANTAGE

This form is to notify Lindsey Dentistry PLLC and its staff of YOUR REQUEST TO CANCEL ALL FUTURE DENTAL APPOINTMENTS which may or may not be scheduled already. This form may be used in regard to recent notification of network participation change with my insurance carrier.

Please include ALL Names and Dates of Birth for all members of your family, household, or dental policy in which you wish to cancel appointments for.

Please ensure you have appropriate authority to cancel on the behalf of any other patient names listed on the form other than yourself.

I understand that Lindsey A. George DDS and Lindsey Dentistry PLLC will still be a PARTICIPATING PROVIDER in United Concordia Dental's CONCORDIA ADVANTAGE Network until 12-31-2024 and that network benefits will be considered as In-Network up to this date.

In addition, I understand that I can choose to continue dental care with Dr. Lindsey A. George DDS at Lindsey Dentistry PLLC ON or AFTER 01/01/2025 on a private pay basis with any possible Out-of-Network benefits, or through another participating insurance, plan, or arrangement option that I may have.

I understand that I should contact my network's Customer Service or employer HR Department to inquire about any Out-of-Network benefits or alternative plan options that may be available to me.

I understand that Dr. Lindsey A. George DDS and Lindsey Dentistry PLLC will be in Network with United Concordia Dental under the ADVANTAGE PLUS network of providers starting 01/01/2025 and will be considered as a NON-PARTICIPATING Provider for plans covered only under the CONCORDIA ADVANTGE network.

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PLEASE CANCEL ALL FUTURE DENTAL APPOINTMENTS AT LINDSEY DENTISTRY PLLC FOR THE BELOW PATIENT NAMES, EFFECTIVE:

Cancel Appointments Effective:

How many Family or Household Patients do you need to cancel appointments for?

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

First Name

Last Name

Date Of Birth

Comments:

I understand that I may request for dental records to be transfered by filling out a Records Release Authorization at LindseyDentistry.com, by Texting 724-819-2843 , or by Calling 724-663-7735 and requesting a release form.

By signing below, I consent that I have proper authorization to sign on the behalf of all named patients above in regard to cancelllation of all future Dental Appointments.

Patient/Legal Guardian Signature

Date