I authorize and give informed consent to my dental provider to perform agreed upon procedures that is necessary for proper diagnosis and dental care. These may include but are not limited to, diagnostic (radiographs and oral exams), therapeutic procedures, local anesthesia and the use of other medications. I confirm that the information on this page and the medical history are correct to the best of my knowledge. I hereby authorize insurance payments to go directly to the dental office. Should I receive payment from insurance company in error, I will forward that payment to Bethesda Dental Health upon receipt. I understand that I am responsible for the cost of the agreed upon treatment and services rendered regardless of my insurance benefits. I also authorize Bethesda Dental Health to discuss my protected health and account information with the persons listed below:

We are pleased that you have chosen our practice for your dental care. Our goal is not only to treat you, but also to educate you as how to prevent dental disease. Our mission is to provide you the highest quality dental care in a pleasant surrounding as efficiently as possible. Please read and sign the following.

Insurance Policy:

• Your dental insurance is a benefit that you or your employer purchases from an insurance carrier. It is your responsibility to be familiar with restrictions, limitations and deductions that may apply to your plan and whether or not we are participating with your insurance plan. As a courtesy, we will submit claims to your insurance company. You are financially the responsible party for the treatment that is provided to you. Insurance companies never guarantee payment or coverage so your coinsurance may be overestimated or underestimated. Your estimated payment is due at the time of treatment.
• Please keep in mind that the quoted amount of coinsurance is approximated based on the information received from your insurance company which may or may not be accurate. Coverage doesn’t mean that your insurance will pay for your “covered” procedure. All claims that are rejected or adjusted by the insurance company will become your additional responsibility and payable to Bethesda Dental Health immediately.
• If Dr. Sheida Larijani or the associate doctors are not participating with your insurance, payment is expected in full at the time of service unless prior arrangements have been made. We will provide you with statement of services rendered to submit to your insurance carrier once the balance is paid in full.
• All insurance claims not paid within 60 days of date of service are due and payable by you immediately.

Financial Policy:

• We are available for you after hours and on Saturdays if you have an emergency there will be a charge of $395.00 in addition to your treatment fees.
• We offer no-interest financing …Financing is subject to approval by the participating financial group. For your convenience, we accept Cash, Master Card, and Visa.
• Balances over 60 days old will accrue an interest charge of 1.5% monthly or 18% annually . $15.00 monthly late fee will also be added to your statement if payment is not received. If it becomes necessary to refer your account to collection agency, you will be responsible for all expenses including but not limited to court costs, reasonable attorney's fees(40%) and an account service fee of $35.00.
• Returned checks are subject to a $50.00 service charge.
• Broken and cancelled recare appointments are subject to $50.00 per half hour. Fortyeight(business) hour notice is required to avoid such charges.
• Procedures that involve laboratory work i.e. crowns, dentures….If you fail to maintain your appointment for delivery of your case, you are responsible for laboratory fees in full and 50% of all procedure fees.
• Rendered dental services cannot be canceled or returned.
  A minimum of $100 deposit is required for treatments other than routine cleanings at time of scheduling. It is non-refundable if you cancel three(3) business days or less before your appointment.
• All patients under the age of eighteen MUST be accompanied by a parent or legal guardian. A parent or legal guardian MUST remain on site while treatment is rendered.
• Copies of your x-rays and records are available at you request. We require a written request forty-eight hours prior. There is 65 cents charge per page for your records and $18 processing fee for copies of your most recent x-rays.

Please sign below if you agree to above and your questions have been answered to your satisfaction.

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 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice.

I have also been informed of, any given right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain 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 health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then 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 is not affected.