New Patient Forms

• Although your insurance may assist you with partial payment of your treatment, the estimated portion that is not covered, is due when services are rendered.
• As a courtesy to our patients, we will file your primary insurance for you. If your insurance has not paid within 90 days, you will be responsible for the entire unpaid balance and payment in full will be expected at this time. We will however, continue to work with you and your insurance company to expedite your reimbursement.

We do not accept assignment of benefits for secondary insurance, however, we will provide a claim form for you so that you may file and be reimbursed by your company.

• I understand and agree that I am ultimately responsible for all fees incurred for my dental treatment regardless of payment or denial of my insurance claim(s) by my insurance company.
• I agree to pay any and all unpaid balance on my account.
• I authorize all insurance benefits paid directly to Drs. Hixon or Burger, or make payment immediately to Drs. Hixon or Burger.
• If payment by the insurance company is made to the insured, I agree to endorse or have the insured endorse the benefits check to Drs. Hixon or Burger, or make payment immediately to Drs. Hixon or Burger.
• I authorize the release of information to my insurance company, attorney or legal representative to obtain reimbursement of any claim(s) or for other reasons.
• A finance charge of 1.5% will begin to accrue after 90 days from the date of service on the unpaid balance of my account even though insurance may be pending.
• A fee of $30.00 will be incurred for each returned check.
• I agree to pay collection costs, attorney's fees, court costs, and interest from the date of treatment if this account is assigned to collection status.
• I have read, understand, and agree to the above terms.
• I authorize this office to discuss my account with a spouse or parent/step parent (if patient is or is not a minor but using parent or step parent insurance).

Clinical
1. I authorize Daniel A. Hixon, Jr. DMD and F. Brandon Burger, DDS, PC to perform all recommended treatment.
2. I authorize the Practice to take radiographs, study models, photos, and other diagnostic aids or materials (collectively, "Diagnostic Material") as needed to make a thorough diagnosis. I authorize that such Diagnostic Material may be released to third-party payors and/or other health professionals.
3. I authorize the use of anesthetics, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination.
Financial
4. I am responsible for payment for all services rendered on my behalf. I understand that payment is due when services are rendered. I am aware that a 1.5% MPR or 18% APR automatically tabulated into my account if my balance is 30 days old or older. Should my account become delinquent, I will be responsible for all additional collection costs, including reasonable attorney fees.
5. A $50 missed appointment fee will be charged to my account for all missed appointments or last minute cancellations by me. I am aware that to hold down operating costs, 24 hours notice of cancellation is required.
Insurance
6. I authorize the Practice to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, any and all information, records, and other Diagnostic Material about my medical history, services rendered, or recommended treatment.
7. I authorize the Practice to submit claims for payment of services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as "signature on file" and assign to the Practice the insurance benefits providing assignment is accepted. I am responsible for payment regardless of coverage provided.