Angela Pourghassemi, D.M.D

2305 Camino Ramon, Suite 230

San Ramon, California 94583

ACKNOWLEDGMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

You May Refuse to Sign This Acknowledgement

I, ______, have received a copy of this office’s Notice of Privacy Practices.

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Please Print Name

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Signature

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Date

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign
Communication barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Other (please specify)

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2002 American Dental Association

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002)

Angela Pourghassemi, DMD

2305 Camino Ramon Suite 230

San Ramon, California 94583

Authorization and Release

I understand that payment is due in full at time of treatment unless prior arrangements have been approved. I understand that I am responsible for payment of services rendered at the time of treatment and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorized payment directly to the dental office of Dr. Angela Pourghassemi from my dental insurance group, otherwise payable to me. 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 of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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SignatureDate

Angela Pourghassemi, DMD

2305 Camino Ramon Suite 230

San Ramon, California 94583

Financial Policy

Payment is due at the time of service. For your convenience we accept cash, checks, VISA and Master Card.

For those who have dental insurance benefits we are happy to assist you by billing your insurance company and maximizing your benefits. However, you are ultimately responsible for the cost of treatment performed. Please remember, insurance is a contract benefit between you, your employer and the insurance company.

Cancellation Policy

Please call to cancel your appointment at least 48 hours prior to the scheduled appointment time. There is a $50.00 cancellation fee charge for appointments cancelled within 48 hours of scheduled appointment time.

Returned Check Policy

There is a $50 fee that applies to Returned checks. If a check is returned, another form of payment for the original check amount in addition to the returned check fee will be required. Unfortunately, should this occur, we will not accept further additional check payments.

I have read the above policies.

Patient signature ______

For Parents Of Children That Are Patients

For those with minor children (under the age of 18) we ask that a parent or legal guardian be present at all dental appointment unless the parent/legal guardian has signed a form giving us permission to treat the child without their presence. If the parent/legal guardian will not be present during the dental visit, financial arrangements must be made prior to the dental treatment, as payments are due at the time of service.

Parent signature ______