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Covatto Family Dentistry

3572 Brodhead Rd,
Monaca, PA, 15061
(724) 728-7576

We would like to take this opportunity to welcome you to Covatto Family Dentistry!( * mandatory to fill )

Our team aims to provide the highest quality dentistry possible by exceeding our patient’s expectation through excellent service and innovative dentistry. Our goal is to provide each individual a comprehensive planning and treatment as if each patient were a beloved family member. This allows us to complete exceptional dentistry that will last a lifetime. We aspire to make every appointment relaxing, comfortable, and life changing by providing our patients with a caring, loving, and professional team!

Please review the following information and if you have any questions please do not hesitate to call us. We look forward to meeting you!

 

The First Appointment

On the first appointment a thorough examination in all areas of your mouth will be done. This will include a detailed examination of the teeth, soft tissue, supporting structures, alignment, bite, and oral cancer check. Based on your dental situation we will let you know what records are necessary so the doctor may accurately assess your dental needs. We think you will agree that the examination appointment is time well spent.

 

Preventative Oral Hygiene Appointment

After your examination, you will be ready to schedule your preventative oral hygiene session. At this time you will be exposed to the latest theories and techniques for controlling periodontal disease. Specific approaches will be recommended for your individual needs. A professional who is dedicated to you receiving maximum longevity from your natural dentition will clean your teeth. This program is clearly one of the most valuable services we offer our patients.

 

Dental Evaluation and Plan for Treatment

After your preventative appointment you will receive an outline of your dental evaluation and plan for treatment. Immediate needs as well as long term objectives will be outlined. Again, our recommendations will be based upon a goal of you receiving maximum longevity from your natural teeth.

Except in cases of very minor treatment needs, an estimate of the approximate costs of treatment will also be made at this time. You are encouraged to ask any questions you have concerning your dental care. We believe that successful treatment is always based on a firm understanding of your dental situation.

We would like to take this opportunity to welcome you to Covatto Family Dentistry!( * mandatory to fill )

Financial Arrangements

Payment is expected at time of service. Our financial coordinator will help you with using our credit card processing service or other financial arrangements when extensive dental care is necessary. We will be sensitive to your financial circumstances within the framework of sound business practices. We want to be concerned with your dentistry, not financial responsibilities. Additionally, certain types of appointments may require a deposit and this will be discussed prior to scheduling.

A Word about Dental Insurance

We participate with many dental insurance plans and as a courtesy we will submit your claims for you. Your insurance policy is a contract between you and your insurance carrier so, we expect you to be interactive with your insurance plan and be responsible for understanding your insurance benefits. In this regard we would like to offer the following tips:

We do our best to calculate your estimated patient financial responsibility through utilizing your insurance “automated” system.

Your estimated patient financial responsibility is expected at the time of service. You are responsible for any amount not covered by your plan.

In the event your insurance carrier does not cover a service we provided or if there is a balance after your insurance has made their payment you are responsible for the remaining account balance.

Treatment and Procedures

Our office is dedicated to providing our patients with the latest breakthroughs in dental procedures and technology. Please visit our website,

www.covattofamilydentistry.com, to view educational videos and images of the amazing procedures that our team offers.

 

We would like to take this opportunity to welcome you to Covatto Family Dentistry!( * mandatory to fill )

Missed Appointments and Last Minute Cancellations

Unless an emergency occurs, you can expect us to be on time. We appreciate you being prompt also. If you are unable to keep an appointment that has been reserved for you, we require 48 hours notice to cancel any appointment. We have a convenient method of confirming your appointment via text messaging. With this prior notice, we will be able to reschedule your appointment and let another patient have the appointment time originally scheduled for you. If you cancel an appointment with less than 48 hours notice, a fee may be applied to your account.

The Recall Visit

Upon completion of your dental treatment we will place you in our continuing care program and pre-schedule for your periodic recall. These appointments are designed to prevent little problems from becoming big or expensive ones.Preventative dentistry is the best and least expensive dentistry, but it is easilyoverlooked and postponed. Don’t miss your checkup! If you think you may beoverdue for this important service, please call us and we will verify it for you.

HIPAA – Health Insurance Portability and Accountability Act

Please view our HIPAA notice of privacy practices form and HIPAA Authorization form found at www.covattofamilydentistry.com

Please complete all forms at your convenience and bring them with you at your first visit. If you have dental insurance please bring your card with you.

We look forward to meeting you. If you have any questions please call the office!

 

Cordially,

 

Covatto Family Dentistry

 

 

Patient Information( * mandatory to fill )
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  •  Retired
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Family Members also to be seen today or in the future as new patients

 If patient is not the responsible party please list responsible individual along with their contact information

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COMMENTS( * mandatory to fill )
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PATIENT DENTAL HISTORY( * mandatory to fill )
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HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING PROBLEMS IN YOUR JAW

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AUTHORIZATION AND RELEASE( * mandatory to fill )

 * I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING 

THE DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION

 RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL 

   CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS.

 

* I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY 

 THE DENTIST DIRECTILY.  I UNDERSTAND THAT MY DENTAL 

INSURANCE CARRIER MAY PAY  LESS THAN THE  ESTIMATION 

 GIVEN AND THAT I AM RESPONSIBLE FOR WHAT INSURANCE DOES NOT PAY

 

 

* I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL

SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.

 

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Notice of Privacy Practices Acknowledgement & Consent( * mandatory to fill )

Our  Notice  of  Privacy  Practices  provides  information  about  how  we  may  use  and disclose  protected  health  information  about  you. The  Practice  provides  this  form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

The patient understands that:  

 Protected health information may be disclosed or used for treatment, payment, or health care operations.  

 The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review.  

 The Practice reserves the right to change the Notice of Privacy Practices.  

 The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.  

 The patient may revoke this Consent in writing at any time and all future disclosures will then cease.  

 The Practice may condition receipt of treatment upon the execution of this Consent. The  

 

By  signing  below,  I  also  consent  to  the  use  and  disclosure  of  my  health  information  to 

treat  me  and  arrange  for  my  medical  care,  to  seek  and  receive  payment  for  services 

given  to  me,  and  for  the  business  operations  of  the  medical  group,  its  staff,  and  its 

business associates.

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Practice Financial Policy( * mandatory to fill )

Our primary mission is to deliver the best and most comprehensive dental care available.

An important part of the mission is making the cost of optimal care as easy and manageable as possible by offering several payment options.



  •  MasterCard
  •  American Express
  •  Discover
  •  Visa

Prepayment

We are happy to offer a 10% discount for services over $300.00 when prepaid in full.

CareCredit

Convenient monthly payments options. Please ask our administrative staff for details & application.

I understand all services are to be paid in full on the date they are completed. I agree that I am fully responsible for the total payment of all procedures performed in this office, this includes any treatment that my insurance may determine not to cover. I understand that in regards to my insurance, an estimate is truly an estimate, as it is impossible for Covatto Family Dentistry to guarantee any type of insurance payment.

Missed Appointments

Appointment times are reserved especially for you for the time you’ve chosen. If for any reason you should need to change your appointment, there will be no charge, provided you give us a 48-hour notice. I understand that if I do not show to my appointment or do not give a 48-hour notice of cancellation a $50.00 fee will be applied to my account. Please help us better serve you & others by keeping your scheduled appointments.

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