I understand the treatment I have received and if applicable the following treatment plan. I authorize release of any information relating to this dental claim. I understand that I am responsible for all costs of dental treatment.
I hereby authorize payment of the dental benefits be sent directly to Dr. Thomas E. Long.
Patient Medical History
Have you ever had or been treated by a doctor for:
SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give permission to the dentist to obtain from my physician any additional information regarding my medical history needed to provide me with the best dental treatment possible.
Consent for Treatment
1. I hereby authorizeDr. Thomas E. Longor designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate to make thorough diagnosis for patient's dental needs (Provide patient's name below).
2. Upon such diagnosis, I authorize Dr. Thomas E. Long or designated staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. I understand that this office files my insurance claims as a courtesy. Any claim not paid within 45 days of treatment is my responsibility.
4. Iagree 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.
5. Lastly, I have received a copy, reviewed, and hereby agree to all office policies.
Person completing this form:
ACKNOWLEDGEMENT OF RECIEPT OF HIPPA PRIVACY PRACTICES
NOTE: You may refuse to sign this acknowledgement.
I have reviewed a copy of this office’s HIPPA Notice of Privacy Practices.
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