PRIMARY INSURANCE INFORMATION
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SECONDARY INSURANCE INFORMATION
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.
Although dental personnel primarily treat the area in and around your mouth your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Women: Are you..
Do you have or have you had any of the following?
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.
Acknowledgement of financial Responsibility of Patient or Guardian
The undersigned patient or individual acting on behalf of the patient agrees as follows:
Authority is granted by undersigned to Center for Dental Health to render treatment to the patient.
I authorized Center for Dental Health to release any information required for payment of insurance claims.
I authorize my insurance benefits to be paid directly to the office of Center for Dental Health realizing that I am responsible to pay for any non-covered services.
I understand that I am responsible for all charges incurred through Center for Dental Health. Payment or estimated co-payment is expected at the time of the undersigned patient visit. Payment arrangements can also be made by applying for a line of credit through Care Credit. The office can assist with the application process.
This authorization will remain in effect until terminated by you, your personal representative, or another individual(s) of legal entity authorized to do so by court order or law.
Accounts no paid in full after 90 days will be sent to a collection agency. The patient, patient’s responsible party or legal guardian will pay any collection fees associated with the collection process. You may also be responsible for up to 12% in annual interest. If your check is returned, your account will be charged for our returned check fee.
I understand that insurance may cover some or all of the costs associated with the treatment performed. I understand that any portion of the fees not covered by the insurance is my responsibility. Dental claims submitted to State Medicaid programs will be supported by our documentation. However, when your annual maximum is reached you will be responsible for the remaining portion out-of-pocket. This out-of-pocket expense will be your responsibility at the State Medicaid fee schedule for the corresponding year the treatment was performed.
I authorize Center for Dental Health to contact me with appointment reminders using the personal information I have provided to Center for Dental Health. This includes phone call, text and/or email. I authorize my immediate family including spouse and/or dependents to schedule and/or confirm appointment(s) date and time.
Cancellation Policy: This office reserves the right to charge a $50 fee for “no show” or late cancellations (less than 48 hours). If you need to reschedule an appointment, kindly provide us with 48 hours’ notice. In instances of repeated non-compliance with scheduled visits, we also reserve the right to allow care on the same day, space available basis or require a pre-payment.
By typing your name, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You agree you are signing for yourself or someone you are legally responsible for, including dependent(s). By signing for someone other than yourself or someone you are not legally responsible for is perjury. Continue typing your name and you consent to be legally bound by this Agreement's terms and conditions.
By signing below, you consent to the use and disclosure of your protected health information by Center for Dental Health for treatment, payment and health care operations. For a more detailed description of uses and disclosures for these purposes, please review our Notice of Information Practices (“Notice”). You have the right to review our Notice prior to signing this consent. The terms of this Notice may change. If the terms do change, you may obtain a revised Notice by simply contacting Center for Dental Health at 802-775-5777, and requesting revised Notice. We will also post any revised Notice in the waiting area.
You have the right to request that we restrict our uses or disclosures of your protected health information that we are otherwise permitted to make for treatment, payment and health care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they are binding on us. Finally, you may refuse to consent, or to the use of the disclosure of your protected health information, but this must be in writing. Under this law, we have the right to refuse to treat you, should you choose to refuse to disclose your Protected Health Information (PHI).
I have reviewed, understand, and agree to the content of the Notice of Privacy Practices.
HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Information stored on our computers is encrypted. In some instances, there is personal information that must be sent through email, please be aware that this could mean a third party may be able to access the information and read it since it is transmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it. Email is very popular and a convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on emails and HIPAA.
The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website:http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf
The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.
By typing your name, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You agree you are signing for yourself or someone you are legally responsible for, including dependent(s). By signing for someone other than yourself or someone you are not legally responsible for is perjury. Continue typing your name and you consent to be legally bound by this Agreement's terms and conditions
I understand the risks of unencrypted email and do hereby give permission to Center for Dental Health to send me personal health information via unencrypted email.
Your information will be encrypted.
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