NOTICE OF PRIVACY PRACTICES
I understand that under the Health Insurance & Portability Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that information can and will be used to:
1. Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read, and understand your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that your organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed. I also understand that you are not required to agree to my requested restrictions, but if you agree then you are bound to abide by such restrictions.
Your insurance policy represents a contract between YOU and your insurance company. Patient portions of dental treatment are DUE AT TIME OF SERVICES. We do offer several methods of payment, and if desired we will assist you with the option of third-party financing. Your insurance carrier does not issue guarantees of coverage and it is your insurance company that makes the final determination of benefits. Therefore, we cannot guarantee any patient portion amounts. As a courtesy to you, we will bill your insurance, but YOU ARE ULTIMATELY RESPONSIBLE for all charges incurred in our office. WE RESERVE THE RIGHT TO BILL YOU FOR ANY REMAINING BALANCES DUE TO INSURANCE DELAYS OR DENIAL OF CLAIMS.
RELEASE OF INFORMATION
I authorize the release of information, including diagnosis, records, and insurance. This information may be released to: