Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Consent for Services and Financial Policy

Please do not print the forms. Submit the forms online only.


  Last name

  MidI

  First name

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arragements, must be paid for in cash at the time services are performed unless other arrangements are made.
We ask that all new patients joining the practice without insurance take care of all charges in full at the initial visit. For all patients with insurance, we will collect the approximate copay for the visit and you will be responsible for any difference.
We will bill your insurance carrier on your behalf at each visit. Your insurance is a contract between you and your insurance company. We will cooperate with you and your insurance company to expedite payment of your claims. If your insurance denies all or part of the claim, you are responsible for payment of the balance. Insurance coverage is different with each policy. Check your policy to see which services are covered along with the percent covered and any applicable deductibles. Dr. Stopka has always been an out-of-network provider so you will be responsible for balance billing. A service charge of $25 per month on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied.
Remember you are a customer of your insurance company and you pay the premiums for your insurance either directly or indirectly. Therefore, your insurance company must be responsible to you and to answer your questions or complaint about your insurance coverage, Insurance coverage should be viewed as an assistance to help you with your dental expenses. It should not be viewed the same as medical insurance.
LEGAL CASES: A patients who are working with an attorney due to an accident, injury or any other circumstance, are asked to make full payment at the time of service.
MONTHLY STATEMENT: A monthly statement will be sent on all showing any balance due which will include an itemized list of the month's transactions.
RETURNED CHECK PAYMENTS: There will be a service charge of $50 for any personal check returned by your bank as not payable for any reason. If this happens, you will be notified by letter and will be allowed fifteen (15) days to make the check good and to pay the service charge.
PAYMENT PLANS: Payment plans are available for any work costing more than $500 to established parents
I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five(5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writiing, within the time payment is due. I further agree that a waiver or any breach of any time or condition hereunder shall not constitute a waiver of any further term of condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
* By checking this box, I understand the above information and agree with its contents. This will serve as my electronic signature for the Administration Form.


HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization.
I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.
I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
* By checking this box, I understand the above information and agree with its contents. This will serve as my electronic signature for the HIPAA Disclosure Form.


24 Hour Cancellation Policy

Our office requires a 24-hour notice for changing or canceling any appointment. To avoid the $50.00 missed appointment charge, we ask that you please give us a least 24 hours prior to the appointment so that we may fill that time slot with another patient. Your cooperation is much appreciated.


*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)