Office Policies & Patient Intake Form
Access the Patient Intake Form at the bottom of this page.
Please review the following important office policies before completing the form.
Simply Orthodontics is committed to providing quality care with respect for your time. Because your appointment time is reserved just for you it is important that you provide at least 48-hours of notice to cancel or reschedule any appointment in our office.
You may reschedule or cancel an appointment by calling 780-765-7600 (you may leave a detailed message if you reach us outside of office hours), or by emailing email@example.com.
Simply Orthodontics reserves the right to charge a cancellation fee of $50 for cancellations or changes made with less than 48-hours of notice and/or to require pre-payment to reschedule a no-show appointment.
Simply Orthodontics does not direct-bill to your insurance company (this includes NIHB) for any services or treatment. Payment is collected from our patients and then the policy-holder is reimbursed by their insurance provider. Simply Orthodontics will provide you with your receipts and assist you with the paperwork required to submit your claim.
If treatment is recommended, Simply Orthodontics will send on your behalf a pre-determination for your proposed treatment. It typically takes 3-4 weeks for you to receive a response from your insurance company outlining your coverage. If you are already aware of the details of your insurance, it is not necessary to await the return of this form before moving your treatment forward.
Understanding Your Orthodontic Insurance
To avoid delays for you, it is important that you call your dental insurance provider and inquire about your orthodontic coverage prior to your first appointment. With this information, we will be able to help you fully understand how your reimbursement will be structured.
Questions to ask:
- Does my plan cover orthodontic treatment?
- At what percentage?
- Is there a maximum amount that is covered per year, or a lifetime maximum?
- If I pay-in-full at the start of treatment, do I get a full reimbursement at that time? If not, what do I need to do to get reimbursed?
- Are there any limitations to my coverage (age of the patient, other)?
- What do I do if I have two insurance policies?
Use of Personal Information Policy
Simply Orthodontics is committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner.
Contact Information is collected from our patients, and includes information such as names, home addresses, work information, telephone numbers and email addresses. Contact Information is collected and used for the following purposes:
- To open and update patient files.
- To send reminders to patients concerning the need for further orthodontic examination or treatment.
- To send patients informational material about our practice.
- To invoice patients for orthodontic services, to process credit card payments, or to collect unpaid accounts.
- To submit insurance forms or to communicate with your insurance company on your behalf.
Financial information may be collected in order to make arrangements for the payment of orthodontic services. Financial information is not disclosed without your prior explicit consent.
Medical Information is collected and used for the purpose of diagnosing oral health conditions and providing orthodontic treatment and appropriate oral health advice. Medical information includes information about your health history, physical condition, and dental history.
Patients’ Medical Information is disclosed:
- To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment, or has asked us to submit paperwork on the patient’s behalf.
- To other dentists, dental specialists or healthcare providers, where we are seeking an opinion and the patient has consented to us obtaining the opinion.
- To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
- To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide an opinion.
- To other healthcare professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either an opinion or treatment.
Dental records are used to assess and monitor dental health, condition, growth and development. Dental records include radiographs, photographs, clinical findings and dental history. Dental records may be anonymously disclosed to other dental professionals and healthcare providers for the purposes of professional teaching and learning.
Dental Specialists in Alberta are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.