Drs. Mello and Van Lanen welcome you
to their practice and look forward to meeting your dental care needs.
Should you have any questions between now and the time of your
appointment, please do not hesitate to contact us.
Here's what you need to
know before coming to your first appointment:
■
Forms
■
Copies of X-Rays
■
Fees & Insurance
■
Forms
Our
New Patient Information packet
is available online. Please download the forms, fill them out, and bring them with you to your
first appointment. The form is in Adobe. PDF format so
you will need the most recent version to open them. If you need Adobe
Reader, please click this button:
The
New Patient Package is a seven
page document that's made up of the following components:
n Patient Information Form
(contains
Medical History questionnaire and authorization for treatment.)
Please fill out all three pages as
indicated. The Insurance Information section is for dental insurance
only. If you don’t have dental insurance, you do not need to complete
this section of the form.
■
Appointment Policy Form
This form outlines our policy for
broken appointments. Please read then sign and date
■ HIPPA Authorization and Policy
After reading the enclosed “Notice
of Privacy Practices”, fill out and sign the top half of the
acknowledgement form (everything above “For Office Use Only”). Parents
of minor children should sign their name on behalf of their child.
Note: The “Notice of Privacy Practices” sheet is for your information
and does not need to be returned to us. Please keep for your files.
■ X-Rays
If you’ve had recent x-rays (see
chart below for details), please obtain copies from your previous dental
provider and bring them to your appointment. This will allow us to have the
most comprehensive information possible and will help reduce the cost of
your first visit.
Note: Please have x-rays sent to you,
not to us because we don't make a chart until you arrive for your first
visit.
|
Peri-Apical or Bite-wing X-rays |
within the past 12 months |
|
Panorex X-ray |
within the past five years |
■
Fees & Insurance
If you have dental insurance, please bring your dental
insurance ID card with you. Fees are due and payable at the time of
service. We will gladly file a claim for the services
provided; however, you are responsible to pay any deductibles or
non-covered charges before you leave.
If your policy is one that pays the
patient directly (instead of the dentist), we ask that you pay all
charges at the time of service; however, we will file a reimbursement
claim for you. Also note that we do not file secondary insurance. If you
have coverage under more than one dental plan, we will file your primary
carrier and give you a superbill to use for your secondary claim.
PLEASE NOTE: Drs. Mello and Van
Lanen do not participate in any dental network plan. This means that if
your policy has both an “in network” and “out of network” provision, you
are reimbursed at the out-of-network rate for our services. Before
coming to your appointment, please check with your insurance company to
make sure you actually have out-of-network benefits as some plans do not
offer this option.
If you have questions concerning the
charges associated with your visit, please contact us. Although there
are some treatments we cannot estimate in advance, we will do our best
to give you idea of projected expenses whenever possible.
