Patient Info

Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

Financial Arrangements

Appointment

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete an online appointment request.

Payment Options

– Insurance Information 

 At One Fine Smile, we want to make it easy for our patients to receive high-quality dental care. That’s why we accept a wide range of insurance options and work with you to get the most out of your provider. One Fine Smile is proud to be networked with: 

  • Delta Dental Premier 
  • Cigna PPO 
  • GEHA Connection Dental* 

– Dental Plans Part of GEHA Connection Dental  

 GEHA Connection Dental is an umbrella provider that is connected with many insurance companies such as: 

  • Aetna Health Management, LLC. (dba Aetna Dental) 
  • Altus Dental, Inc. 
  • Ameritas Life Insurance Corp (First Ameritas Life, First Reliance Standard Life Ins Co., Physicians Mutual Insurance Company, Reliance Standard Life Ins Co., Security Life Insurance Company of America, The Standard Ins Co NY) 
  • Best Life and Health Insurance Co.  
  • Careington International Corporation & Careington Benefit Solutions (Equitable, Merchants Benefit Administration, Inc), BrightBenefits, Anthem, Anthem Blue Cross Blue Shield or Empire 
  • Dental Network of America  
  • Dental Select (Select Benefits Group) 
  • DenteMax (Always Care Benefits, Beam Dental, Blue Cross Blue Shield of MI, ConnectiCare, Kaiser Permanente Dental Choice, Level Benefits Inc., dba Level, Mutual of Omaha, Starmount, TruAssure, Unum) 
  • Dominion National, formerly Dominion Dental Services (Blue Cross and Blue Shield of AZ, Capital Blue Cross, Kaiser of the Mid Atlantic) 
  • The EPIC Life Insurance Company 
  • Employee Benefit Management Services (EBMS) 
  • FCE Benefit Administrators, Inc. 
  • First Dental Health, Inc. 
  • Foundation for Medical Care (HealthEdge) 
  • GEHA (Plans-FEHBP, Connection Dental Plus, FEDVIP- which may include eligible former TRICARE retirees) 
  • Group Resources Incorporated 
  • Guardian Life Insurance Company of America 
  • HealthComp, Inc. 
  • HealthPlex, Inc. 
  • Health Resources, Inc. (Dental Health Options, Paramount Dental, Promedica’s Medicare Advantage plan) 
  • Humana Dental Insurance (Central States Funds, Humana Dental Access Discount Card, Humana Dental PPO, Humana Dental Traditional Preferred, Humana Federal Advantage/FEDVIP (AL, AZ, CA, CO, UT), Humana Gold Plus (HMO), Humana One) 
  • Kansas City Life Insurance Company 
  • Lincoln Financial Insurance Company 
  • MetLife Insurance Company 
  • Mid-American Benefits, Inc. 
  • National Rural Electric Cooperative Association Group Benefits Program (NRECA) 
  • NovaNet Inc. (Alternative Ins Resources, Aflac PPO Dental (formerly Argus Dental & Vision Inc), Arm LTD, The Benefit Group Inc, Benefit and Risk Management Services (BRMS), Boulder Admin Svcs, CareFirst Blue Cross Blue Shield, Chesterfield Resources, CoreSource, Cypress Benefit Admin, DD Services, Inc, Direct Care Admin, Equian LLC, Group Benefit Services, HealthFirst, Med-Pay, Inc., Northern Illinois Health Plan, Nova Healthcare Admin, Planstin Administrative Solutions, Preferred Benefit Admin, United Claims Solutions, United Furniture Workers Insurance Fund, Varipro) 
  • Pequot Plus Health Benefit Services 
  • Preferred Health Professionals (Bricklayers Local 15, Cement Masons and Plasterers Local 518, City of Pasco, Construction Industry Laborers, Greater KC Laborers, Missouri Cooperatives, Painters District Council #3) 
  • Principal Financial Group 
  • Renaissance Dental  
  • Shasta Administrative Services 
  • Solstice Benefits, Inc. 
  • Sun Life Financial Inc. 
  • TransWestern Insurance Administrators 
  • TriStar Benefit Administrators (formerly Am. Administrators) 
  • United Healthcare (Blue Shield of California, Dental Benefit Providers, Inc.) 
  • Medicare Advantage Plans: AARP MedicareComplete Profile (HMO), Erickson Advantage Signature with Drugs (HMO-POS), Rocky Mountain Health Plan Medicare, UnitedHealthcare MedicareComplete Assure (PPO), UnitedHealthcare Dual Complete (HMO SNP), UnitedHealthcare Dual Complete LP (HMO SNP), UnitedHealthcare Dual Complete RP (Regional PPO SNP), UnitedHealthcare Medicare Silver (Regional PPO SNP) HMO  
  • UltraBenefits, Inc. 
  • United Concordia Inc. (BCBS MN Medicare Advantage and Commercial, First Priority Life Insurance Company, Highmark, Inc., Highmark West Virginia, Highmark Delaware, HMO of Northeastern Pennsylvania, Inc., d/b/a First Priority Health, Highmark Choice Company, Highmark Select Resources Inc., Highmark Benefits)  
  • United Medical Resources, Inc. (UMR) 

We do everything we can to make dental care attainable, even working with any PPO in or out of network. However, because the insurance market can be restrictive, there is a possibility that some policies might require us to bill the balance of non-covered treatments. If you have questions about your specific plan, we ask that you please call our office to discuss your options.

Terms and conditions

This plan is only good at One Fine Smile. It does not include dental procedures performed outside of One Fine Smile by specialists.  Referrals to specialists will be at One Fine Smile’s discretion.

To be an independent member you must be 18 years of age or older.  Adult premiums apply to patients 13 years and older and children premiums apply to patients 12 years of age and younger.

This plan may not be combined with any other offers, discounts, insurance coverage, or other marketing advertisements.

Once signed up for the plan, you will receive the benefits for 12 consecutive months.  New contracts will be available 30 days prior to expiration.  In order to continue as a member for this plan a new enrollment form will be required.  You have the right to cancel this plan at any time in writing, however the membership fee is non-refundable.

This plan is non-transferable.  It may not be transferred to any other family member.

Due to the substantial discounts offered with this plan, all membership fees and treatment payments are due at the time of service to receive the discount.  Any services not paid for on the date of service will be billed out at the regular fees. 

No refunds will be given if a spouse or dependent does not use the plan, moves, or obtains dental insurance.  Nor will there be any refund if Orthodontic services are not completed for any reason or patient is non-compliant with trays. 

Treatment completed prior to membership does not qualify for discount.

Prescriptions are not included in this plan.

Two no-shows or cancellations with no 48 hour notice will result in cancellation of your membership without refund. 

The One Fine Plan cannot be used in conjunction with extended payment options such as Care Credit or other 3rd party payment plans.  

One Fine Plan is only available at the office of One Fine Smile.

Special free consultations!

– Ask us about a smile makeover to enhance your smile

– Complete dental implant services from start to finish

– Oral appliances to treat sleep apnea