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You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process insurance claims.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:(This includes step parents, grandparents and any care takers who can have access to this patient's records)
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Our goal is to provide you with quality care and attention during your appointment.
We ask that you make every effort to keep your appointments. This appointment time has been set aside for you; missing it will disrupt proper sequencing of your care and delay completion of your treatment. Our office utilizes a confirmation system that will contact you before your appointment by email, text or phone call. We ask that you please confirm your appointment via this system so we can adequately prepare for your appointment. If you miss this confirmation call, please call our office to confirm your appointment. We ask that you call at least 24 hours before your appointment if you need to cancel or reschedule. Failure to call 24 hours before will result in a broken appointment fee. We understand that family emergencies or sudden illnesses do arise, but please call the office to reschedule if this happens. When we have adequate notice of a cancellation, we are more likely to be able to offer that time to another patient. After three broken or missed appointments you will be dismissed from our practice.
Payment is due at time of service. Our office accepts cash, personal checks, Master Card, Visa, Discover, American Express and Care Credit.
As a courtesy to you, we will help you process all of your dental insurance claims. Insurance coverage is subject to eliminations, exclusions, waiting periods, frequencies, age restrictions, deductibles, and maximums. It is your responsibility to be familiar with your dental plan. You may need to contact your insurance company to obtain your dental plan benefit information. We will provide you with an insurance estimate. This however is not a guarantee that your insurance will pay the exact amount estimated. Your benefits may differ due to a number of reasons as stated above. Your insurance company and your plan benefits ultimately determine the amount paid. Our office is committed to providing the best treatment for our patients. All charges you incur will be your responsibility, regardless of what your insurance covers. We must emphasize that as your dental care provider our relationship is with you, our patient, not your insurance company. We encourage you to be up to date with your coverage.
We ask that you please read and sign this letter as confirmation that you understand our office expectations. You will be given a copy to keep for future reference.
Thank you for coming to our office. We look forward to getting to know you and your family.
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.