I acknowledge that I have received a copy of this Dental Practice’s HIPAA Notice of Privacy Practices.
Please note: It is your right to refuse to sign this Acknowledgement.
Name of Insurance Company(ies)
all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions
The above-named doctor may use my or my dependent’s health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.
I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that patients, parents, guardians or personal representatives are responsible for all fees and services rendered for treatment of themselves or their dependents. I accept full financial responsibility for all charges for services or items provided to me or the patient. I understand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of all charges