HIPAA Consent & Financial Policy

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HIPAA Patient Consent

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. You have the right to revoke this consent, in writing, at any time. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). A detailed description of the HIPPA policy is available for your review upon request.

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

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

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.

Office Financial Policy

Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible.

  1. Our office provides insurance claim submission as a courtesy to our patients.
  2. We offer a 10% senior courtesy to patients 62 years old and over.
  3. We accept cash, personal checks, Care Credit, and all major credit cards.
  4. We offer a 5% courtesy accounting adjustment to patients who pay for their treatment in full on the day of service.
  5. Copayments are due at time of service, unless prior payment arrangements have been made.

I agree to pay a fee of $40.00 for all returned or canceled checks.

A fee of $50 is charged for patients who miss or cancel more than 2 times in a calendar year without 24 hours notice.

authorize Kusch & Raubolt to bill my dental insurance, and use my personal health information as necessary for billing purposes. I request my dental insurance to pay Kusch & Raubolt directly for services rendered. I understand that my dental insurance carrier may pay less than the actual bill for services, and that I will be responsible for payment of dental services rendered on my behalf.

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.

Your information will be encrypted.

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