Patient Information Form

Dental Insurance Information

PRIMARY INSURANCE:

SECONDARY INSURANCE:

Medical History Information

Do you have, or have you had, any of the following?

Receipt of Treatment Plan and Financial Agreement

Notice of Privacy Practices:

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).


Release of Information:

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.


Consent to Obtain Patient Medical History:

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.


Consent for Case Documentation:

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.


Some procedures may require a revision which may be an additional cost to the patient:


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. *