ASSIGNMENT AND RELEASE
1, the undersigned certify thal I (or my dependenl) have insurance coverage with
sign directly to Dr.
all insurance benefits, ii 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Emergency Contact: (Specify an adult we should contact in the event of an emergency)
Patient Consent & Notice Of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ) , I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- I have been informed by you of your Notice of Privacy Practices describing the uses and disclosures of my health information. I have been given the right to review such Notice Of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice Of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice Of Privacy Practices.
-I Understand that I may request in writing that you restrict how my private information is used and/or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
-I understand that l may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
-I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.
This authorization shall remain in effect for 12 months from the date signed. I understand I may refuse to sign this authorization with the understanding that you may refuse to perform treatment.
OFFICE USE ONLY
We attempted to· obtain consent in acknowledgement of this Notice Or Privacy Practices, but unable to do so for reasons documented below.
Prince George Dental
10545 South Crater Rd. Petersburg, VA 23805804-732-8557
Patient Responsibility Agreement
Patient Responsiblllty - Payment Is Due At Time Of Service
We have several payment options available
5% discount for treatment paid in full prior to the time of treatment
Patient Visitors Policy
Private Dental Insurance
In consideration for services rendered to me or my dependent child, I authorized Dr. Shahareyar Sayyar and associates to bill my insurance carrier for all services provided and that all payment for services rendered will come directly to Shahreyar S. Sayyar. I give authorization to the release of any information requested by my insurance company with respect to insurance claims. I assume all responsibility for any portion of treatment cost not paid by my insurance company. I agree that if I do not have insurance or my insurance Is not active at the time of treatment, I AM RESPONSIBLE FOR PAYING IN FULL AT THE TIME OF SERVICE FOR ALL TREATMENT. If for any reason my account becomes delinquent, I agree to pay an interest rate of 1.5% p er month, or 18% annually, on balance more than 60 days old, plus any attorney's fees that may be added.
I have read and understand the Financial, Insurance , and Patient responsibilities as noted in this authorization