Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us. We will be happy to help.
have read and understand the HIPAA agreement given to me. I hereby authorize Broadway Smiles and its affiliates, its employees and agents to release to my personal health information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number. I authorized any personal health information or other information may be released to:
I, hereby authorize payment directly to the Dental Office for the group’s insurance benefits otherwise payable to me. I understand that I am responsible for all the costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostics, photographic, and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/ medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/ medical histories and other information about my dental treatment to the third party payers and/or other health professionals.
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.
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