New Patient Forms

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices:
You have the right to read the Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice can be read at the following link. Notice of Privacy Practices We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will update the revised Notice of Privacy Practices on our website and you may view it at any time, which will contain the changes. Those changes will be effective from the date the notice is revised and issued on the website and may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:


Address: 510 Ranch Trail, Suite 102, Irving TX 75063
Telephone: 972-597-2227


Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation.

Valley Ranch Family Dentistry ("VRFD") is committed to providing you with the best possible care. We are pleased to discuss our fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.

Our Policy
1) Payment is due at time of service.
2) Valley Ranch Family Dentistry provides insurance company billing as a courtesy to our patients. We will do our best to look up your dental benefits and inform you of your estimated out of pocket costs. You acknowledge that at best, VRFD can only provide an estimate. This amount may be subject to adjustment when the dental service(s) claim(s) are adjudicated by the insurance company. In addition, certain insurance companies have annual limitation for the amount of dental services that can be reimbursed within each plan year. If you or your family exceed these annual limitations in any plan year, you will be responsible for the full amount of dental services that exceed the particular plan’s limitations. The patient is responsible for monitoring the amount of his/her remaining benefits for any annual benefit period. The patient may not rely upon any information provided by VRFD staff regarding his/her remaining benefit in any such benefit period. You acknowledge that you will be responsible for any charges listed on your explanation of benefits even if it was not collected at the time of service.
3) You acknowledge that you will promptly pay any balances dues upon receiving a valid invoice by the due date indicated on the invoice. Valley Ranch Family Dentistry sends its invoices via email or mail.
4) The claims we submit to insurance companies indicate that you have assigned those benefits to VRFD. However, if you are paid by the insurance company instead of VRFD, you then become responsible for the total account balance and payment would be expected immediately.
5) You as a patient are always responsible for any charges that are not covered by your insurance.
6) We accept cash, checks, visa, master cards and care credit.
7) Adult patients are responsible for their charges. If the patient is a minor, the adult accompanying the minor and his/her parents or guardians, are responsible for full payment at time of service.
8) If the patient is an unaccompanied minor, Non-emergency treatment will be denied unless charges have been pre-authorized by their legal guardian.
9) If you are covered by Medicare, Medicaid, Champus, Worker’s Compensation or any other government sponsored program, please discuss your payment situation with our office staff prior to arriving at the VRFD office on the date of service.
10) It is our policy to charge finance fees at 1.5% for outstanding patient balances after the balance has been outstanding 30 days. In addition, all payments returned due to non-sufficient funds will be subject to a NSF fee of $25.00. The patient is responsible for any fees incurred by VRFD for collections including, collection agency fees, court costs, attorney fees and legal costs. If an invoice is forwarded to collections, a 30% delinquent payment fees will be added to the invoice to cover collections charges. The patient is responsible for these charges.

Thank you for understanding and accepting our Financial Policy. Please let us know if you have any questions or concerns.
I consent to the above policy.