ACKNOWLEDGEMENT & CONSENT
Acknowledgement of Insurance Payment Authorization: I hereby authorize and direct payment of the dental insurance benefits otherwise payable to me for services rendered, directly to Plano Top Dental. In the event that the insurance company misdirects payment to me, I understand that I am responsible to immediately remit such payments to Plano Top Dental.
Acknowledgement of Financial Responsibility: 1 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 the event payments are not received by agreed upon dates, I understand that either a 1-42% late charge (18% APR) or a $15 late charge per late payment may be added to my account. I further agree to inform Access Dental/Blue Hills Dental of any address or phone number change within 30 days of such a change. In the event I fail to do so I authorize Plano Top Dental to use all due means, including the use of credit history records, to ascertain my new address for billing purposes.
Notice of Privacy Practices: I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.
Acknowledgment of Dental Materials Fact Sheet: I acknowledge that I have received and read the Dental Materials Fact Sheet prior to starting restorative dental work at Plano Top Dental.