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1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs.2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.4. Last, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In th event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (1.8% APR) may be added to my account.
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Heart (Surgery, Disease, Attack)
Congenital Heart Disease
High Blood Pressure
Mitral Valve Prolapse
Artifical Heart Valve
Artificial Joints (hip, knee, etc.)
Allergies or Hives
Hepatitis A (infections) B (serum)
Cold Sores/Fever Blisters
Sickle Cell Disease
Epilepsy or Seizures
Fainting or Dizzy Spells
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication
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I authorize the health care provider named above to submit claims for payment for services to the healthcare service plans or insurance companies named below, on my behalf and in my name, and assign to such provider the group insurance benefits otherwise payable to me, but not to exceed the provider's actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.
Click here to read the Notice of Privacy Practices. By checking the box below, you acknowledge the receipt of Notice of Privacy Practices.
I authorize the physician, dentist or other health care provider named above to release to hospital or health care service plans, insurance companies, self-insurers, or their representatives, any and all information and records (including x-rays) about my medical history, or about services rendered or treatment given to me, that is needed to review, investigate or evaluate any claim for benefits.If my coverage is under a group master agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall remain effective for up to five years from this Date.
I know that I have the right to receive a copy of this authorization if requested.
Health Insurance Portability and Accountability Act, HIPAA provides national standards to protect the privacy of personal health information. To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required HHS to adopt national standards for electronic health care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.
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