My Form

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Patient Information
Spouse or Responsible Party Information
Insurance Information
Consent for Services
I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis.

Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

I agree to the use of anesthetics and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

I give consent to the doctor's or designated staff's use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

I 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. I also understand, if applicable, that Dentistry at Greenfield is submitting my insurance claim only as a courtesy to me, and that I am responsible for contacting them, as well as my insurance company, if there are any issues.
HIPAA Acknowledgement and Consent Form
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:

- Conduct, plan and direct my treatment and follow‐up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

- Obtain payment from designated third‐party payers.

- Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of the Notice of Privacy Practices; containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website). 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 at the address(es) below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.
Health History Form
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
  • AppointmentsMissed appointments or appointments not cancelled within a 24 hour period will be assessed a fee of $45.00.
  • StatementsAll patients, including those with insurance, will receive monthly billings until account is paid.
  • Delinquent AccountsAccounts over 120 days will be sent to a third party for collection.
  • Payment is due in full at time of treatment.