SECTION A: Patient Giving Consent
SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Information
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
Signature
I,
, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Personal Representative (if applicable)
Authorization for Disclosure
I authorize disclosure of information regarding my billing, condition, treatment and prognosis to the following individual(s):
This dental information may be used by the persons I authorize to receive this information for medical/dental treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until nine (9) months after my death or
, (date or event) at which time this authorization expires.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
HIPAA Patient Consent
I understand I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).
- Obtaining payment from third party payers (i.e. my insurance company).
- The day to day healthcare operations of your practice.
I have also been informed of and given the right to review and secure a copy of your "Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA". I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent in writing at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Office Policy
We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals we need your assistance and your understanding of our office policy.
1. Your insurance is a contract between you, your employer and the insurance company. As a service to our patients, this office will bill all primary and secondary insurance companies without charge.
2. We must emphasize as dental care providers, our relationship is with you, not your insurance companies. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date of service. Any balance not payable by the insurance company will be the responsibility of the patient. If you anticipate any difficulties in paying these balances, you should contact the practice administrator prior to treatment so financial arrangements can be made. All co-payments must be made at the time of each visit for any insurance that we accept.
3. Account balances are considered delinquent after sixty (60) days and are subject to collection charges. Interest may also be assessed.
4. Appointments are commitments that you will be expected to keep. Time is set aside exclusively for you and you should plan to arrive promptly as scheduled. We make every effort to see our patients on time.
5. You may be charged for missed appointments if we are not notified at least 48 hours in advance. Your insurance will not cover this charge, and you will be responsible for payment. This charge is not automatic but will be made at the discretion of the Doctor in accordance with each circumstance. Continual missed appointments may result in loss of appointment privileges.
6. Should you have any questions regarding this office policy, please see the practice administrator or one of our administrator team members for assistance.
