By Signing below, I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
To the extent permitted by law, I consent to use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to my practice of the dental benefits otherwise payable to me.
To the extent permitted by law, I authorize this dental practice (or designee) to collect information about my medical history from my previous health providers.
To the extent permitted by law, I authorize case documentation in the form of intraoral/extraoral photographs. If published patient identifying will be removed prior to publication.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR INDIVIDUAL CHARGES INCURRED DURING THE COURSE OF YOUR TREATMENT, INCLUDING HOSPITALIZATION, EVEN THOUGH I MAY HAVE INSURANCE OR THIRD-PARTY COVERAGE. I RECOGNIZE THE COST IF THIS CARE MAY EXCEED THE AMOUNT REIMBURSED BY MY INSURANCE.
*Every effort is made to provide correct estimates of insurance coverage. These are subject to change without our knowledge. *