PATIENTS CONSENT FORM |
|
Polices &
Responsibilities described in the New Patient
package are listed below. |
Financial/Insurance
Policy |
|
The patient/guardian
agrees to be and hereby is fully responsible for
total payment of procedures performed in this office
including any amounts not covered by any dental
insurance or prepayment program that the patient may
have. All rights of exemption are waived and
signature below agrees to pay all cost of
collections, including finance charges, late fees,
court cost and attorney's fees. |
|
Appointment Policy |
|
You will be given an
appointment card and it is then your responsibility
to remember and keep your appointment. Our office
reserves the right to charge a broken appointment
fee of $50.00, especially if you miss more than one
or you simply do not show up without calling. |
|
We
require a forty-eight (48) hour notice for
rescheduled appointments.
Keeping your
appointments maintains your dental health and also a
healthy relationship with our office. |
|
HIPPA |
|
I understand that,
under the Health Insurance Portability &
Accountability Act of 1996 (HIPAA), I have certain
rights to privacy regarding my protected health
information. I understand that this information can
and will be used to: |
|
Conduct, plan and
direct my treatment and follow-up among the multiple
healthcare providers who may be involved in that
treatment directly and indirectly. |
|
Obtain payment from
third-party payers |
|
Conduct normal
healthcare operations such as quality assessments
and physician certifications. |
|
I have been informed by
Dr Van Horns’ office of their Notice of Privacy
Practices containing a more complete description of
the uses and disclosures of my health information. I
have been given the right to review such Notice of
Privacy Practices prior to signing this consent. I
understand that Dr Van Horn’s office has the right
to change its Notice of Privacy Practices from time
to time and that I may contact their office at any
time at the address above 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 to carry out
treatment, payment or healthcare operations. I also
understand the office is not required to agree to my
request restrictions, but if they do agree then they
are bound to abide by such restrictions. |
|
I understand that I may
revoke this consent in writing at any time, except
to the extent that the office has taken action
relying on this consent. |
|
I have read and
understand all polices in the Patient Handbook that
was given to me by Dr. Van Horn’s Office. All rights
of exemption are waived and signature below agrees
to abide by the policies set forth in this handbook. |
|
Note:
All rights of exemption are waived and signature
below agrees to pay all cost of collections,
including finance charges, late fees, court cost and
attorney's fees. |
|
________________________________________________________________ |
|
Parent/Guardian
Signature
Date |
|
(Please sign
and return this page to the Office Manager.) |
| |
