Dear Patient, Thank you for choosing the Center for Oral Diseases. You are scheduled to see the following doctor:
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- Mervyn Price
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1 Dear Patient, Thank you for choosing the Center for Oral Diseases. You are scheduled to see the following doctor: Vikki Noonan, DMD, DMSc NPI number: In order for your visit to be covered by your medical insurance carrier, it may be required to have a primary care physician referral before you can be evaluated in our specialty practice. Please call your primary care physician s office and ask them to either fax a referral for your visit(s) to the Center for Oral Diseases at or send this via to: ajhamb@bu.edu. Should you have any questions please contact us at One Place Boston, MA T
2 Dear Patient, This letter confirms your appointment with Dr. Vikki Noonan on at. In order to expedite your visit to our office, we have enclosed a patient data form and patient medical history questionnaire. Please fill these forms out completely and bring them to our office on the day of your visit; kindly arrive 20 minutes prior to your appointment to allow for registration. Should it be necessary to cancel or reschedule your appointment, kindly call us with a 24 hour notice. Please remember to obtain a referral from your primary care physician if that is a requirement of your medical insurance. If your insurance requires a referral and one is not obtained, you will be responsible for any fees. Payment will be required at the time of the appointment. Our office staff is available to process your dental or health insurance forms for reimbursement; we accept MasterCard, Visa, and Discover for your convenience. Enclosed is a map of the BU Medical Center Campus. Your appointment is at the following location: Moakley Building, 830 Harrison Avenue, Suite 1500, Boston, MA More information about our center, including directions to our office locations and parking options, can be found at: If you have any questions, we can be reached at the Center for Oral Diseases: Sincerely, Center for Oral Diseases One Place Boston, MA T
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5 FINANCIAL AGREEMENT Patient s Name _ Appointment Date I understand that I will be evaluated today by a doctor of the Center for Oral Diseases and there will be professional charges (doctor s fees) for this consultation. It is possible that the consultation visit charges may not be covered by my medical and/or dental insurance plans. If that is the case, I agree to be fully responsible for payment for such services. I also understand that at the time of the consultation, I will be given a more detailed financial estimate for my specific treatment. I will be responsible for payment of these charges if they are not covered by my medical and/or dental insurance plans. Patient signature: One Place Boston, MA T
6 Privacy Practices I,, hereby acknowledge that I have reviewed a copy of the Center for Oral Diseases Notice of Privacy Practices. I have been given the opportunity to ask any questions that I may have and to request a copy of the Privacy Practices Permission Note My name is. You have my permission to speak with my family regarding my treatment here at the Center for Oral Diseases. Signature of patient or parent/guardian Date signed Authorization to Release Photographs I authorize the Center for Oral Diseases and its doctors to use all photographs taken of (patient name) for use in Educational Journals, Texts, and Presentations. I may cancel this authorization to the extent allowed by law. If I do decide to cancel this authorization, I understand that the doctor or practice may have already released information about me after I gave permission. I know that canceling this authorization would not prohibit any release of photography by the doctor or practice in reliance on my original authorization. To cancel this agreement, I must write a letter to the doctor or practice advising of my wish to cancel my authorization to disclose photographs taken of me by this practice. Signature of patient or parent/guardian Date signed One Place Boston, MA T
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