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APPOINTMENT INTENTIONS FORM

REQUEST TO MAINTAIN DENTAL APPOINTMENTS

United Concordia Dental - CONCORDIA ADVANTAGE

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

Please include all Names and Dates of Birth for all members of your family, household, or policy in which you wish to KEEP AND MAINTAIN appointments for.

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 level.

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PLEASE KEEP AND MAINTAIN ALL FUTURE DENTAL APPOINTMENTS AT LINDSEY DENTISTRY PLLC FOR THE BELOW PATIENT NAMES:

How many Family or Household Patients do you have?

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 Dr. Lindsey A. George D.D.S. and Lindsey Dentistry PLLC will not be a Participating Provider with United Concordia Dental's Concordia Advantage network level of plans after 12/31/2024. I accept that I may or may not have any out of network benefits applicable to continuing my care with Dr. Lindsey George and Lindsey Dentistry PLLC. If I am eligable for any benefits, it is expected that I will be reimbursed directly from United Concordia Companies Insurance AFTER care has been provided, and payment in-full of the practice's usual & customary fees are made due at the time of service. I also understand that I may have other applicable insurance coverage, plans, or arrangments that may still be considered for all applicable In-Network benefits and contract terms.

By signing below, I consent that I have proper authorization to sign on the behalf of all above named patients.

Authorized Patient/Legal Guardian Signature

Date