Dental Registration Form

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with our Office Administrator, Carrell Clarke. We accept Cash, Checks, Master card, Visa card, American express card, and Discover card. We also offer financing through Carecredit and Lending Club.
• I authorize and give consent to perform any necessary or advisable services during diagnosis and treatment.
• I authorize consent for provider and staff to communicate with all physicians, hospitals, laboratories and insurance claims department pertaining to diagnosis and treatment on my behalf. I understand that I have the right to deny consent of release of my information at anytime.
• We are “Out of Network” with all dental plans. If your dental insurance company allows for “Out of Network” coverage, we will file all dental claims and you will be responsible for paying the portion not covered by your dental insurance carrier. You are solely responsible for the full payment of all services not covered by your insurer and payment will be due at the time services are rendered. For all dental plans where “Assignments of Benefits” are issued to the subscribers we will expect payment of the full reimbursement amount plus your portion if any, no later than 48 hours after receipt. According to NYS Law we cannot write off any balances for services that were already paid for by your insurance carrier.
• We must emphasize that, as dental care providers, our relationship is with you, not your insurance company therefore you are responsible for all charges from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Spyridon J. Condos, DDS, LLC. I understand that I am financially responsible for any balance.