Health assessment

Simple Sleep Quiz

More than 20 million Americans suffer from Obstructive Sleep Apnea (OSA). Despite this high prevalence, 93% of women and 82% of men with moderate to severe OSA remain UNDIAGNOSED and UNWARE that they have a deadly disease.

Please complete this short questionnaire to determine your risk of OSA. Your information is confidential and will only be share with healthcare providers for diagnostic and treatment purposes.

Assignment of Insurance:

Our office understands the value of insurance benefits to our patients and we gladly accept assignment of insurance benefits. Rarely does an insurance company cover an entire bill. We will do our best to estimate your deductible and the portion that will be covered by your insurance carrier. However, any balance remaining is your direct responsibility. This includes any non-covered services, yearly deductible, or co-payments specific to your individual insurance plan. Since it would be impossible for us to be familiar with the details of every insurance plan due to it being an agreement between you, your employer and your insurance company, we ask that you be aware of your financial responsibilities under the terms of your policy.

Payment Options:

Savings Program for Prepayment In Full (benefiting Cash and Out of Network Insurance Patients): Our office offers a savings program for patients willing to pay for the entire cost of their treatment prior to treatment beginning. We extend a 10% savings for prepayment in cash and 5% for prepayment with credit card. This option is available on an individual basis. We will continue to offer a cash discount for our patients who do not have insurance.

For patients with out-of-network insurance, the savings program does require that you file and accept your own insurance. There is no assignment of benefit to our office. We will be happy to file and accept benefits for patients with out-of-network insurance but cannot offer a cash discount for this service. For patients with in-network insurance, we will continue to honor your discounted rates and file your insurance.

Outside Financing Options: We accept CareCredit and offer 6- and 12-month payment plans with 0% interest options.

Overdue/Past Due Accounts: If your account becomes more than 90 days delinquent, Cole & Gentry Dentistry reserves the right to turn your account over to an outside debt collector. Once your account has been turned over for collection, Cole & Gentry will not be able to assist you with your account.

Dependents Age 18-26: We recognize that many of our patients aged 18-26 are covered by their parent/guardian’s insurance. We do require that each patient give us permission to discuss treatment and financial information with the financially responsible party. Once permission is granted, we require the parent/guardian to sign a responsible party agreement. This agreement states that the responsible party assumes liability for any treatment that we provide with the patient’s permission.

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1Contact Information
2Epworth Sleepiness Scale
3Health Symptoms:
Please enter your contact information to complete this brief health assessment.
Name*
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