Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESREQUESTING SOCIAL SECURITY NUMBER
This office requests at least one guarantor of each account provide his/her Social Security Number. Each employee/subscriber with insurance coverage is requested to provide his/her Social Security Number. Businesses, like this office, are allowed to request Social Security numbers for valid business purposes. Please go online to ssa.gov or call the Social Security Administration at 1-800-772-1213 if you have any questions regarding our policy.Providing a Social Security Number is voluntary. However, if the requested Social Security Number is not provided, services may not be provided. The denial of services may include, but may not be limited to, acceptance of insurance, submission of insurance claims and pre-authorizations, extension of credit, acceptance of means of payment other than cash including insurance checks, personal checks and credit cards, and dental treatment. Social Security Numbers are only shared with other organizations for valid business purposes: i.e. correspondence with insurance companies, credit extension, debt collection.
