Dr. David C. Ashley, DMD & Associates
Please tell us about yourself:
Assignment and Release
I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
When was your last dental:
CONDITION OF YOUR TEETH:
MedicaI Information Release Form
(HIPAA Release Form)
Release of Information
This Release of Information will remain in effect until terminated by me in writing.
CANCELLATION POLICY: When we make your appointment, we are reserving time for your particular needs. As a courtesy, we contact you to remind you of that reserved appointment. Therefore, we ask that if you must change an appointment, to please contact us at least 48 hours prior to your reserved appointment time. Failure to do so, either by failing to arrive for your appointment or cancelling without proper notice, will result in a charge of $75.OO per hour reserved, per occurrence. By signing below, you acknowledge that you have read and understand our cancellation policy.
PAYMENTS: Payment is due at the time services are rendered. We accept cash, check, Visa, MasterCard, Discover, and American Express. We also offer interest free financing through Care Credit for those that qualify. We take the time to explain your dental treatment and your expected out-of- pocket expense. When treatment plans are presented it is an estimate of what we anticipate your dental insurance will cover, based on your policy benefits. In the event your insurance does not cover a procedure or payment is less than anticipated, you are responsible for the balance. If your insurance company does not pay your claim within 60 days from the time services are rendered, you are responsible for the balance. Please keep in mind, your dental benefits are based on a contract between you and your insurance company. You are responsible for accurately reading and understanding your dental coverage. By signing below, you acknowledge that you have read and understand our payment policy.