Our goal is to provide you with the best dental care available. A clear understanding of our financial arrangements is essential for a successful doctor/patient relationship.

As a condition of the treatment performed by the providers of Newport Dental Arts; financial arrangements must be made in advance for the full cost of the proposed treatment. The practices' vitality depends upon payment for services rendered and it is the responsibility of the patient to satisfy the costs incurred in dental care. Financial arrangements on the part of each individual must be determined prior to treatment completion.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are rendered.

Individuals who carry dental insurance understand that all dental services furnished are charged directly to the patient and that said patient is personally responsible for payment of all dental services provided, regardless of dental insurance reimbursement. As a customer courtesy, this office will help prepare and submit patients' insurance forms as well as assist in making collections from the insurance companies. However, this dental office cannot render services on the assumption that our charges will be paid in part or in full by an insurance company. (Please understand that the amount to be paid by your particular policy is pre-determined and agreed to by your employer and the insurance company. If you have any questions about the amount the plan will pay or the treatment your plan will cover, you should refer these questions to your employer.) Additionally, there may be a deductible, a co-insurance factor, and a yearly maximum to be considered. Most policies cover what they consider a "usual and customary fee". However, the insurance company sets these fees, and they are not always the same as the fees that may be charged in this or any office. All these factors may combine to reduce the benefits you will ultimately receive. We will do our best to see that you receive full benefits within the structure of your particular dental plan. If your insurance company has not paid their portion of the charges within 60 days, the account will revert to your responsibility.

I understand that the fee estimate listed for any proposed dental care can only be extended for a period of three months from the date of diagnosis diagnosed and/or examination. I further acknowledge that the proposed treatment plan can shift and/or change from the diagnosed treatment plan once treatment is begun due to unforeseen circumstances beyond Dr. Wilhelm's control.

I grant my permission to Dr. Wilhelm and/or Dr. Wilhelm's financial coordinator, to telephone me at home or at my place of business to discuss matters related to this form.

We strive to provide the utmost in dental care, and we appreciate your trust. Your time with us is exclusive and has been set aside for your treatment. We honor your time and we expect you to honor ours. Your appointment time has been especially reserved for you. Should you be unable to keep your appointment, a minimum notice of 48 business hours is appreciated. Failure to give adequate notice may result in a $50.00 charge. Should you have to change your appointment, please call during business hours.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act). I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following:

• Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment.
• Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
• The day to day healthcare operations of your dental practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA. I understand that your reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

By submitting this form you agree to the above mentioned consent statement's