Spouse or Responsible Party Information
Consent for Services
Leslie C. Flahaven, DDS504 Lambs RoadPitman, NJ 08071
With my consent, LDC Dental, LLC may use and disclose Protected Health Information (PHI) about me to carryout Treatment, Payment and Healthcare Operations.Please refer to LDC Dental, LLC's Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing thisconsent. LDC Dental, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to LDC Dental, LLC, Privacy Officer at 504 Lambs Road, Pitman, NJ 08071. With my consent, LDC Dental, LLCmay call my home, cell phone or other designatedlocations, text my cell phone, email and leavea message on voicemail or in person in reference to any items that assist the practice in carrying out Treatment, Payment and Healthcare Operationssuch as appointment reminders, insurance items and any call pertaining to my clinical care. I have the right to pay out of pocket in full for treatment and instruct LDC Dental, LLCto refrain from sharing information about that treatment with my insurance company.
With my consent, LDC Dental, LLC may mail to my home, e-mail or fax to a specified number or other designated locations any items that assist the practice in carrying out Treatment, Payment and Healthcare Operations such as appointments, reminder cards, pre-treatment information, dental claims and patient statements.
LDC Dental, LLC will disclose to me any breach of unsecured protected health information.
A separate authorization is required from me for LDC Dental, LLC to use or disclose any of my protected health information for marketing purposes.
By signing this form, I am consenting to LDC Dental, LLC use and disclosure of my Protected Healthcare Information to carry out Treatment, Payment and Healthcare Operations. I also acknowledge availability to rereview and/or receiving a copy of LDC Dental, LLC Notice of Privacy Practices.
I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent, LDC Dental, LLC may decline to provide treatment to me.
LDC Dental, LLC has my permission to discuss my Protected Health Information to carry out Treatment, Payment and Healthcare Operations with
LDC Dental Associates
504 Lambs Road | Pitman, NJ 08071 | (856) 589-2188
Written Financial Policy
Thank you for choosing LDC Dental. Our primary mission is to deliver the best and most comprehensive dental care available. This service is based on a friendly team and professional understanding between our office team and patient. An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
Cash, Check, Visa, Mastercard, American Express or Discover Card We offer an 10% courtesy accounting adjustment to patients who pre-pay for their treatment in full with cash or check or 5% courtesy adjustment for pre-payment in full with credit card.
Convenient Monthly Payment Plans1 from Care Credit
LDC Dental requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.
For plans requiring multiple appointments, alternative payment arrangements may be provided.
For patients with dental insurance, we are contracted with 8 insurance companies (Delta, Cigna, Assurant, United Concordia, Horizon Blue Cross/Blue Shield, Aetna, MetLife & United Healthcare.) We are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement for your treatment.2
Failure to pay in one of the above agreed upon manners (delinquent accounts) may be turned over to the collection agency. In this case, the patient is responsible for all costs associated with the collection procedure; including attorney fees where applicable. LDC Dental charges $15.00 for returned checks.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
1 Subject to credit approval
2 However, if we do not receive payment from your insurance carrier within 90 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.