Patient Information & FORMS
FORMS FOR NEW & ESTABLISHED PATIENTS:
PRINT NEW PATIENT FORMS (takes you to another page to download & print forms).
PATIENTS OF RECORD- You may update information with our office by selecting one of the online forms below:
Patient Registration Update Medical History Update Insurance Information Update
Patient Disclosure Authorization Form Responsible Party Form (for Dependents)
X-Ray Transfer From PREVIOUS Dentist X-Ray Transfer From Classic Concepts
DENTAL INSURANCE
Classic Concepts Family Dentistry accepts most dental insurance and we are happy to file a claim on your behalf.
Did you know? If you have a PPO policy, you may see any dentist of your choice!
While ultimately, your insurance policy is between you and your carrier, we make every effort to seek details of your plan to provide estimates for your services! Call Jennifer at 563-285-5600, Ext. 2 to learn more.
Our office is In-Network with:
- BCBS Federal Employee Program
- Delta Dental Premier & Hawki
- MetLife PPO & MetLife Federal
- United HealthCare PPO & United HealthCare Medicare
- Wellmark Blue Dental (also called BCBS Grid PLUS)
- Wellmark Medicare Advantage
The American Dental Association has excellent resources to use when it comes to selecting a dental plan. Please use link below:
FINANCIAL
Your estimated patient portion is due at the time of service. We are happy to have your treatment Pre-Authorized by your insurance carrier at your request.
- We accept the following forms of payment:
- Cash & Check
- MasterCard
- Visa
- American Express
- Discover
- Online Payments
Use office Code: 10160-4G5C, your account number and billing zip code
- Care Credit
- 6 or 12 month interest deferred Options
- Reduced APR and Fixed Monthly Payments (24, 36 & 48 months)
- Financing by Synchrony Bank
- Apply at www.CareCredit.com or call 800-677-0718
- Green State Credit Union
- Dental Loans to fit any budget, 6 - 60 Month Terms
- Credit Card Option with 0% for 6 months
- Fast & easy application process
- Manual underwriting based off ability to pay
- Submit online or call Melisa Henley at 319-248-7163
MINOR PATIENTS
A parent or legal guardian must accompany any minor children to their dental appointments and remain on the premises.
APPOINTMENT CANCELLATION POLICY
Your appointment time is reserved exclusively for you! We kindly ask for a minimum of a 24-hour business day notice. If you are unable to keep your reserved appointment and wish to avoid a minimum of a $50 service fee please call our office as soon as possible to reschedule. This allows us the opportunity to offer time to another patient waiting for care.
Nondiscrimination and Accessibility Notice
Classic Concepts Family Dentistry, PC complies with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. Classic Concepts Family Dentistry, PC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
Classic Concepts Family Dentistry, PC provide free aids and services to people with disabilities to communicate effectively with us, such as, but not limited to:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as Qualified interpreter or Information written in other languages
If you need these services, please visit our office, contact by phone (563)285-5600 or e-mail us at info@classicconceptsdental.com .
If you believe that Classic Concepts Family Dentistry, P.C. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:
Dr. Katharine J. Pins
100 S. 4th Avenue, Unit 2
Eldridge, IA 52748
(563) 285-5600
Fax (563) 296-5622
info@classicconceptsdental.com
Your grievance may be in person, by mail, fax or email. If you need help filing a grievance, we are available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201
800–368–1019, 800–537–7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html