Michael S. Fife, DDS, DICOI, FMII, Inc.

1801 Professional Drive, Sacramento, California 95825

916-974-1160

Welcome to Craftsman Dental Care!

So that we may better serve you, please indicate the purpose of your visit today:

Are you interested in any of the following services?

Please tick your dental anxiety level.

(NO Problem)     (Fear Beyond Belief)

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

PATIENT INFORMATION

Please Print Legibly, Thank You.

Patient Name:
Preferred Name
Mailing Address
City
State
Zip
Patient DOB
Sex
Social Security #
Drivers License #
State where Issued
Home #
Cell #:
E‐mail:
Your Employer’s Name
Job Description/Title
Work #
Employer’s Address
City
State
Zip
Person to Call in Case of Emergency
Relationship
Phone #
Who may we thank for referring you to our office?

PRIMARY DENTAL INSURANCE INFORMATION

Insurance Company Name
Ins. Phone #
Group #
Union #
Insurance Company Address
City
State
Zip
Policy Holder’s Name
DOB
Sex
Policy Holder’s Mailing Address
City
State
Zip
Policy Holder’s Home #
Work #
Cell #
Policy Holder’s Social Security #
Policy Holder’s Employer Name
Job Description/Title
Drivers License #
State where Issued
Policy Holder’s Employer Address
City
State
Zip

I understand that regardless of my dental insurance status, I am ultimately responsible for the balance of my account for any professional services received. I certify the information that I have provided on this form is true. I will notify Craftsman Dental Care of any changes in the above information as soon as I am aware.

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Guardian's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

SECONDARY INSURANCE INFORMATION

Insurance Company Name
Ins. Phone #
Group #
Union #
Insurance Company Address
City
State
Zip
Policy Holder’s Name
DOB
Sex
Policy Holder’s Mailing Address
City
State
Zip
Policy Holder’s Home #
Work #
Cell #
E-mail Address
Policy Holder’s Social Security #
Drivers License #
State where Issued
Policy Holder’s Employer Name
Job Description/Title
Human Resources Contact
HR Phone #
Policy Holder’s Employer Address
City
State
Zip

I understand that regardless of my dental insurance status, I am ultimately responsible for the balance of my account for any professional services received. I certify the information that I have provided on this form is true. I will notify Craftsman Dental Care of any changes in the above information as soon as I am aware.

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Guardian's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Assignment of Benefits

Patient Name:

I hereby instruct and direct my dental insurance provider to pay my dentist (Craftsman Dental Care) for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered; by check, made out and mailed to:

Michael S. Fife, DDS, Inc.
1801 Professional Drive
Sacramento, CA 95825

If my current policy prohibits direct payment to my dental provider, I hereby instruct and direct my dental insurance provider to make the check out to me and mail it to the following address:

Michael S. Fife, DDS, Inc.
1801 Professional Drive
Sacramento, CA 95825

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. The insurance payment(s) will not exceed my indebtedness to Craftsman Dental Care, and I have agreed to pay any balance of professional service charges over, above, and not covered by the insurance payment(s).

A photocopy of this Assignment shall be considered as effective and valid as the original.

I authorize the release of my personal information to any insurance company, adjuster, or attorney involved with my dental care.

If necessary, I authorize Craftsman Dental Care to initiate a complaint to the State Insurance Commissioner(s) for any reason on my behalf.

Signed at (City)
on (Date)

Signature of Patient (or Guardian if Under 18 Years of Age)

Use your mouse cursor or the tip of your finger to sign below

Witeness

Use your mouse cursor or the tip of your finger to sign below

OFFICE POLICY

PATIENTS WITH DENTAL INSURANCE: As a courtesy to you, our office will gladly submit rendered services to your insurance. We are able to bill to all traditional insurance plans. We DO NOT participate with DMO or HMO plans. Under these plans, there is NO COVERAGE when treatment is rendered by a non-participating dentist. Please check your type of plan carefully. PATIENTS WITH DELTA DENTAL INSURANCE: Dr. Fife is a “PREMIER” provider (not PPO). However, we are still able to bill your insurance for all PPO plans, even though Dr. Fife is out-of-network.

AUTHORIZATION TO RELEASE INFO AND ASSIGNMENT OF BENEFITS: I certify that I , (or my dependent) have(has) dental insurance coverage and assign directly to Dr. Michael Fife all insurance benefits, if any, otherwise payable to me for services rendered. I hereby authorize the doctor and/or his staff to release all necessary personal information to my insurance company in order to secure the payment benefits.

PAYMENTS: We accept cash, check, Visa, MasterCard, and Discover. Payment of your “estimated” portion is due at the time services are rendered, such as your annual deductible and/or percentage of the treatment not covered by insurance. As a courtesy, we will gladly contact your insurance in order to provide an “estimate” of your patient portion. However, despite this, we cannot guarantee the payment of insurance benefits nor can we provide 100% accuracy of this estimated amount since many factors are involved that determine the actual payment of benefits once submitted and processed by your insurance. Keep in mind that many insurance companies base their quoted percentage of coverage (i.e. 100%, 80%, 50%, etc.) on their own fee schedule, and not our office’s actual fees, which may result in a balance due higher than expected. Should an outstanding balance due result after your insurance company processes your claim, you will then be sent a statement. Payment in full is due by the due date printed on the statement. Our office policy does not allow partial payments. If a credit balance should result after insurance processes your claim, a refund will be promptly issued to you.

UNPAID INSURANCE CLAIMS: All dental services rendered, whether or not covered by your insurance, are ultimately the financial responsibility of the account holder. We will give your insurance company 60 days to remit payment. If there is still no payment after this time, in order to keep your account current, the balance will be due on the due date printed on the statement. It is the responsibility of the account holder to follow up with their own insurance company regarding the non-payment of a claim. Should our office eventually receive payment from your insurance after it has been paid by you, a prompt refund will be issued.

PAST DUE ACCOUNTS: If payment is not received by the due date printed on the statement, then your account is considered “past due”. We reserve the right to charge a $10.00 per month billing charge on all past due accounts. If the balance is still unpaid after 90 days, the account will be turned over for further collection action. If an account is turned over to our collections agency and/or our attorney for collection, the account holder will be responsible for ALL attorney fees will be added to the outstanding portion of the account, and will also become the financial responsibility of the account holder.

PATIENTS WITHOUT DENTAL INSURANCE: Payment in full is expected at the time services are rendered. We accept cash, check, Visa, Mastercard, and Discover.

BROKEN/MISSED APPOINTMENTS: We request at least 48 business hours’ notice before cancelling or rescheduling an appointment. Less than 48 business hours make it difficult for us to fill the opening left in our schedule. Friday, Saturday and Sundays are not considered business hours. We reserve the right to charge your account $50 per hour reserved for the appointment if not notified.

Dr. Mike reserves the right to update and make changes the above-stated office policies at any time without prior notification.

By signing below, I verify that I completely understand, agree, and accept the policies outlined above. I further acknowledge that I am responsible for all dental services rendered me and my dependents (if applicable).

Responsible Party Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:
Relationship to patient: