Consent Form - Parent / Guardian

Consent Form – Parent / Guardian

Consent of Disclosure of Protected Health Information, Billing, and/or Medical/Dental Information

1. I hereby consent for Milford Pediatric Dentistry to use and disclose personal protected health information (“PHI”) on the voicemail systems at the following phone number(s):

2. Return Messages (please check one):

3. Billing Information:

I hereby consent for Milford Pediatric Dentistry to discuss this patient’s billing & payment information with the following person(s):

4. Medical / Dental information via telephone or in person:

I hereby consent for Milford Pediatric Dentistry to discuss this patient’s medical/dental information with the following person(s):

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

This consent will remain in effect until revoked by me in writing.

Assignment of Benefits:

I hereby assign all dental benefits to which I am entitled including private insurance to Milford Pediatric Dentistry, Inc. This assignment will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not paid by my insurance. I herby authorize assignee to release all information necessary to secure payment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.