JOINT REPLACEMENT:

WOMEN ONLY, Are you:

Allergies, Are you allergic to or have you have any reaction to:

CHD:

PRESENT CONDITIONS:

PREMEDICATION

• I hereby authorize the dentist and/or the associates, assistants, or dental hygienists to take x-rays, impressions, study models, and other diagnostic aids deem appropriate by the dentist to make a thorough diagnosis of the above patient’s dental needs.
• I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
• I consent to the administration of anesthetics and other medications as may be considered necessary and advisable by the dentist. I understand that there are risks and benefits that may occur and are possible in the performance. I can ask for an explanation of possible risks and benefits.
• I give consent to the dentist’s or designated staff’s use and disclosure or any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations.
• I acknowledge that I am responsible and hereby agree to pay for services, at time of appointment upon checking in, provided to me or my dependents by O’Brien Dental PLLC (DBA “Sitwell Dental”), its dentists and/or associates, assistants, or dental hygienists. I understand that payment or co-payment is due at the same time of services, unless other arrangements have been made.

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 maybe 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 you of your 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 this 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 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 health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you 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 you have already taken action in reliance thereon.

1. I hereby authorize all health care providers to use and/or disclose the protected health information (“PHI”) described below to me or directed below. The purpose of this request is for personal reasons. 
2. I hereby authorize the release of the PHI, defined here as the patient’s complete dental record, including treatment, prognosis, financial, billing, and insurance information. I understand that my personal billing, financial and insurance information may be disclosed to those in section 3 in order to be able to process claims with the insurance company and/or for personal reasons.
3. In addition to the authorization for release of my PHI, I authorize disclosure of information regarding my/my spouse or domestic partner/my dependent’s billing, condition, treatment and prognosis to the following individual(s) (please caregivers that may accompany children to appointments):

4. This medical information may be used by the persons I authorize to receive this information for dental/medical treatment or consultation, billing, or claims payment, or other purposes as I may direct.
5. This authorization shall be in force and in effect until I am no longer a patient at this practice.
6. I understand that I have the right to revoke this authorization, in writing, at any time. Such revocation will not affect actions taken by the requesting person prior to the date he/she received the written revocations.

MESSAGES

In the event that you do not notify us that you are unable to keep your appointment, we have a adopted a no-show/late cancellation policy in our practice if not confirmed within 2 business days. Please understand that when you do not cancel an appointment you are unable to keep in a timely fashion, it may prevent other patients from receiving the care they need. Failure to notify us of a cancellation for a scheduled appointment less than two full business days in advance may be subject to a late cancellation fee of $50.

PLEASE NOTE:

Any unpaid balances after 60 days of work completion are subject to a 1.75% monthly finance charge. Annual percentage rate is 21%