Name of Insurance Company: ________________________Policy Number:_________________________________________
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
TO THE PATIENT/ PERSONAL REPRESENTATIVE- 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 encourage you to read it carefully and completely before signing 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.
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. 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 child’s protected health information to carry out treatment, payment activities and healthcare operations.
Pediatric Dentistry at Vinings is committed to providing your child with the best possible dental care. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to treatment. Payment for all services provided by the practice is due in full at the time the services are rendered. If you have private insurance, we will file your visit. Your full co-payment is expected per visit. You will be billed in full for any services that your insurance plan deems to be a non-covered service or any balances due after we have received payment from your insurance carrier. All patient balances are payable upon receipt of the statement. We accept Cash, debit & credit cards (Visa, MasterCard, AMEX, and Discover Card) as payment for services rendered. Personal checks are not accepted. Refunds will be handled as a credit to the patient’s account or issued a check. Pediatric Dentistry at Vinings reserves the right to turn any patient over to collections if it is deemed that the account has been in default of the payment obligations or compliance of this policy. You will be responsible for all collections related fees which may represent 1/3 of the balance due.
All our patients are seen on a reserved appointment basis. In most cases, the procedure you are scheduled for requires that a definite amount of time be set aside with the dentist or hygienist. This assures the best possible care for your child. Every effort in scheduling is made to minimize waiting. All appointments must be verbally confirmed with the office within the week of your appointment. The office will make every attempt to confirm your appointment. If you must reschedule your appointment, please contact our office as soon as possible. Giving us this courtesy allows us to schedule another patient who wishes to be seen. Appointments that are not cancelled at least 24 hours in advance will be considered a broken appointment and will be charged a $25.00 fee. A good dentist/patient relationship is based upon understanding and good communications. If you have any questions about financial arrangements, please feel free to speak with our Business Manager. We will make every effort available to you to clarify any misunderstanding you may have concerning your account. We are here to help you.
I have read, understand and agree to the terms of the above Financial and Appointment Policy of Pediatric Dentistry at Vinings.
Signed: _____________________________________________________ Date: _______/_______/_________
Child’s Name «LName», «FName» «MI» «PrefName»_____ HEALTH HISTORY
GENERAL HEALTH REVIEW Please review your child’s past and present health history. Mark the box ONLY if your child has the condition now or has been treated in the past.