If other than self, please complete:

PRIMARY INSURED PARTY INFO (CARD HOLDER)

SECONDARY INSURED PARTY INFO (CARD HOLDER)

I hereby acknowledge that I have received a copy of this practice's Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

Are you allergic or ever had a reaction to:

*Surgery and/or anesthesia during early pregnancy can potentially harm a developing baby.

*Antibiotics (such as penicillin) may alter the effectiveness of birth control pills.

I certify that I have read and understand the questions above and that the information that I have provided is correct the best of my knowledge. I understand that it is important for my doctor to be familiar with my complete medical history. I authorize Dr. Gregory A. Lehman, Dr. Michael A. Menis, and designated staff to perform an examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of X-rays and photographs required for this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

We welcome and encourage discussion of services and fees prior to treatment. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor, but usually does not pay the entire cost. Insurance coverage is variable between insurance companies, and even between individual policies within the same company. Benefits can also vary between in-network and out of network providers. If you have concerns that our practice is not in your insurance network, we strongly encourage you to call your insurance company and verify. There are deductibles that must be fulfilled prior to payment of benefits, and many plans have annual maximum allowances that, once exceeded, do not provide additional benefits.

Insurance companies use the terms “allowable,” “U & C” (usual and customary), and “UCR” (usual, customary, and reasonable) when determining the portion of fees that they are responsible for paying. These fees are determined and agreed upon by the insurance company and your employer, and are often lower than the actual fees charged. Because the insurance contract is between the insured and the insurance company, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company.

If you would like to know what your approximate financial responsibility will be for services to be rendered, we will gladly send a “pre-estimate” to your insurance company for them to review. This process does require a consultation and X-ray prior to the procedure and can take four (4) weeks or longer to receive a reply from your insurance company.

If you would rather proceed with treatment without a pre-estimate, we require payment of the portion estimated not to be covered by your insurance plan at the time the service is rendered. Actual eligibility, benefits, and coverage can only be determined by your insurance plan upon receipt and processing of the claim once services are provided. When the insurance payment is received, any amount in excess of your account balance will be refunded to you promptly. Conversely, any balance remaining after insurance pays will be your responsibility. Any balance remaining after insurance pays will be due immediately. Partial payments will not be acceptable.

For any reason, if your insurance company has not paid your claim within 90 days, you will be responsible for the remaining balance. Our office will gladly continue to work with your insurance and provide any information required to process the claim. Any balance not paid within 90 days will be subject to a 11⁄2% monthly interest charge. In addition, should the account be referred to a collection agency, you will be liable for all attorney fees.

My signature authorizes the release of information requested by the insurance company, which is necessary to process my claim. I hereby assign payment of benefits otherwise payable to me to Lehman & Menis Dental Implant and Oral Surgery Specialists. I understand that I am financially responsible for all charges not covered by my insurance company.

If you have any questions, we will be happy to assist you.

I understand that as part of my dental care, Lehman & Menis Dental Implant and Oral Surgery Specialists creates and maintains health records that describe my health history, dental information, symptoms, examinations, test results, diagnoses, procedures, treatment, and plans for future care or treatments I may receive. I understand that health information collected and stored will be used for the following:

• To support my care and treatment at Lehman & Menis Dental Implant and Oral Surgery Specialists (treatment)
• For continued treatment among health professionals who are involved and contribute to my health care (treatment)
• For billing purposes, including information regarding my diagnosis, treatment, and services rendered (payment)
• For insurance claim processing by third-party payers for verification of services billed (payment)
• A tool for routine healthcare operations such as assessing quality improvement (healthcare operations)

I understand that the Notice of Privacy Practices from Lehman & Menis Dental Implant and Oral Surgery Specialists defines more information regarding the use and disclosure of my protected health information as well as my rights to my health information. By signing this, I acknowledge that Lehman & Menis Dental Implant and Oral Surgery Specialists has offered me a copy of their Notice of Privacy Practices. I acknowledge and understand the rights that I have over my protected health information. I authorize the use and disclosure of my protected health information as specified in the Notice of Privacy Practices. I authorize the use and disclosure for treatment, payment, and healthcare operations purposes for Lehman & Menis Dental Implant and Oral Surgery Specialists.

I understand that I am ultimately responsible for all charges incurred for dentistry performed at Lehman & Menis Dental Implant and Oral Surgery Specialists office including balances left after insurance payment has been received.

This consent will continue forever unless I cancel it by writing to: Lehman & Menis Dental Implant and Oral Surgery Specialists, 850 Munshaw Ln, Crystal Lake, IL 60014; if the consent is cancelled, it will not change releases that have already been made prior to the date of cancellation.

I understand that I can get an electronic copy of the Notice of Privacy Practices at www.lehmanmenis.com