To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status.

SECTION B: TO THE PATIENT/GUARDIAN --- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decided whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SIGNATURE

I have had full opportunity to read and consider the contents of this Consent form and your notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

If a personal representative on behalf of the patient signs this Consent, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. PLEASE ADVISE US IF YOU WANT A COPY.

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my Consent.

Acknowledgment of Receipt

Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgment that you have been notified that our NOTICE OF PRACTICE POLICIES can be obtained via our office. This document is printable via the website for your records.

                HIPAA website: http://www.hhs.gov/ocr/hipaa/finalreg.html

You May Refuse to Sign This Acknowledgement*

I have received acknowledgment of this office’s Notice of Privacy Practices.

For Office Use:

• We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:
• Individual refused to sign
• Communications barriers prohibited obtaining the acknowledgment
• An emergency situation prevented us from obtaining acknowledgment
• Other (Please Specify)

Appointment Guidelines

Rescheduling Your Appointment:

We pre-plan and prepare for your visit and hope you’ve done the same. Your appointment has been reserved especially for you. Should any scheduling changes be required, we require at least 36 hours advance notice to avoid a $75 cancellation fee.

Insurance Guidelines:

We are glad you have dental insurance to help you with partial assistance in affording your dental care. Please know that we will do everything possible to see that you receive the full benefits of your insurance 

policy. As a courtesy, we will verify your dental insurance benefits. Dental insurance is different than most medical insurance plans and it is important to be aware of the following:

• Insurance is an agreement between you and your insurance company. The insurance relationship constitutes an agreement between the insurance carrier, the employer, and the patient. Our dental office is not a party to this contract. As such, we can make no guarantee of estimated coverage of payment.
• Full dental fees are not always covered. Insurance companies base the amounts they pay on restrictive fee schedules, regardless of what the actual fee may be. Our fees are something higher than the average fees allowed by your carrier.
• Not all your care may be covered. Not all dental services that are necessary for excellent dental health are covered benefits in all contracts. This depends on the kind of plan your employer has purchased.
• Deductibles and Co-payments must be collected. Deductibles and co-payments are built into most plans and their required payment is strictly regulated by state law. Your Employee Benefits Director can usually help you become familiar with your plan, its restrictions, and your out-of-pocket expense.

Here’s What We Promise To Do:

1. Complete insurance claim forms and submit to your carrier within 24 hours of treatment.
2. Use current American Dental Association coding for correct reporting of procedures.
3. Accept direct payment from your carrier and keep track of balances.
4. If necessary, re-file your insurance a second time within a 30-60 day period.
5. File a pre-estimate to your insurance company, per your request, for treatment your doctor recommends.

Your Responsibilities Will Be To:

1. Pay fees not covered by your plan at the time of treatment or as otherwise arranged in advance. Your estimated copay is based on the information provided by your insurance over the phone. Your final amount due is subject to final approval and payment by your insurance company.
2. Provide our office with necessary information concerning your insurance coverage to allow correct filling of claims
3. Understand that your plan is a contract between you, your employer, and the insurance carrier. Our office will do all we can to facilitate claims payment, but we do not have the power to force your insurance company to pay.
4. Pay any account balance not paid by your insurance after 90 days & after 2 billing attempts from our office.
5. Be aware and understand non-covered benefits by your insurance, such as limitations on fillings, waiting periods, missing tooth clause and frequency limits on all services.

Office Guidelines:

• A statement will be mailed to you at the end of each month and receipt of payment is due upon receipt of statement.
• A fee of $35 will be charged to your account for any check returned by the bank for any reason. (After 2 returned checks, the office will no longer accept payment by check in the future).
• As a courtesy, we make every effort to remind patients by telephone, text, or email prior to their appointment but please do not depend on this courtesy.
• I authorize Braydich Dental to use my signature on file as approval/authorization on any payments made over the phone or automatic withdrawals set up on my account.