Patient Accounts

New Patient Forms:

The New Patient Form is in Adobe Acrobat (PDF) format. If you do not have Acrobat Reader, get a free copy by clicking on the link below. The Acknowledgement form does not require the reader and will open in a new browser window.

Please print the New Patient Form, fill it out, and bring it with you for your appointment. Also, after reading the Notice of Privacy Practices, print the Acknowledgement form below, sign it, and bring it in, too.

New Patient Form (Acrobat PDF form)

Acknowledgement of Receipt of Notice of Privacy Practices (web page)

Insurance:

Dental insurance is intended to cover some, but not all of the cost of your dental care. Most plans include coinsurance provisions, a deductible, and certain other expenses which must be paid by the patient at the time of services. Reimbursement amounts are not, and never have been, a guideline for quality care.

We can file most insurance claims for you. Please bring your insurance plan information with you on your first visit. We will work with you to ensure that you receive the maximum benefits to which you are entitled.

Payment:

Payment is expected at time of service. If you have insurance, you will be expected to make an estimated payment for that portion not covered by your insurance plan. For that portion of costs not covered by insurance, we offer several payment options:

Cash or Personal Check
Credit Card - We accept MasterCard, Visa and Discover.
Care Credit Medical/Dental Card - This card allows you to take up to 6 months interest free, to pay your balance. You can apply in our office or apply online.
Longer term bank loans - For extensive treatment plans, longer term loans are available. Call our office or stop by for details.

If you have any questions about your insurance plan or payment options, please call Our staff at (970) 407-1001 or e-mail us at info@fortcollinsdentist.com.

Patient Account Information:

© Copyright 2003-2006 Dental WebSmith, Inc. and Roger L. Northen, Jr., D.D.S., P.C. All rights reserved. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.