DENTAL INSURANCE INFORMATION
Authorization for treatment
The undersigned hereby authorize Dr. Taylor Clark, Dr. Jayson Clark, and/or Dr. Jonathan Pluid to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the patient's dental needs. I also authorize Dr. Taylor Clark, Dr. Jayson Clark, and/or Dr. Jonathan Pluid to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the patient and further authorize and consent that Dr. Taylor Clark, Dr. Jayson Clark, and/or Dr. Jonathan Pluid choose and employ such assistants as deemed fit. I also understand the use of anesthetic agents embodies a certain risk. We send out courtesy reminders for your appointment. Please let us know if you wish not to receive text or email communication.
PLEASE PROVIDE US WITH A COPY OF YOUR PHOTO ID & INSURANCE CARD. THANK YOU!
Office Use Only
Dear Valued Patient;
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. "HIPAA" provides penalties for covered entities that misuse personal health information.
We have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
The most common reason why we use or disclose your health information is for treatment, payment, or specialty referrals. For treatment purposes we may disclose information for scheduling your appointments, treatment planning, prescribing prescriptions, referring you to a specialist, or getting your health information from another healthcare provider. For payment purposes we may disclose information when asking for information on your dental plans or other types of payment options, sending statements or claims, and collecting money (whether collection action through our office or an official collection agency). For specialty referral purposes we may disclose information when finding and informing an additional healthcare provider of needed treatment and concerns.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we generally will not ask you for special written permission.
In limited situations, the law allows or requires us to disclose your health information without your permission. Not all situations listed will apply in our office; however, we are still obligated to let you know all rights.
APPOINTMENT CONFIRMATION: We may call or write you in regard to scheduling appointments. We may also call or write to notify you of further treatment or service available to you and your healthcare needs.
AUTHORIZATIONS: We may not make any other uses or disclosures of your health information without a written authorization from you. The content of the appropriate authorized form is determined by federal law.
Both you and our office are authorized to initiate the authorization process. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization form, we can not make the disclosure. If you do sign one, you may revoke it at any time unless we have already acted upon the request. When revoking a prior authorization we must receive written notice, which will then be kept in your file.
YOUR RIGHTS: The law gives you many rights regarding your health information
CHANGE TO THIS NOTICE: We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. If we do change our notice, we will post the new notice in our office and have copies available in our office.
COMPLAINTS: You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint in writing with us by notifying our Privacy Officer, and we will not retaliate against you for filing a complaint.
We offer several financial options for your convenience. Knowing this ahead of time allows us both to arrange for completion of your treatment. If after reviewing the following information, please let us know if you have any questions.
I understand the responsibility for payment of services provided in this office for myself or any dependents is mine,due and payable in full at the time of service. I also understand there are no in house financing options and I must use one of the options listed above. I do understand all delinquent accounts will be released to an outside collection agency and assessed a $50 charge. A 24 hour notice is required for all cancelled appointments. Missed appointments without the required 24 hour notice are subject to a $59 charge. Returned checks will be assessed a $25 charge. I hereby authorize payment of dental benefits directly to All About You Dental.