Patient Registration and Insurance

Please correct the errors described below.

Dental Insurance 1st Coverage

Add new row

Dental Insurance 2nd Coverage

Add new row


  • I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.
  • I authorize release of any information for the purpose of evaluating and administering claims for insurance benefits.
  • I authorize release of any information concerning my treatment to another dental specialist for the purpose of referral care.
  • I hereby authorize payment of insurance benefits directly to the dentist
  • I understand that my dental insurance company may pay less than the actual bill for services. I understand that I am financially responsible for payments in full of all accounts. I agree to be responsible for payment of services not paid by my dental inusrance company.

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.

Health Questionnaire


The undersigned agrees that the information above is accurate.

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.



The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used "HIPAA" provides penalties for covered entities that misuse personal health information.

As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use" and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would"include teeth cleaning services.

Special circumstances would require us to release your personal information. Examples would be public health risks, lawsuits & similar proceedings, law enforcement, deceased patients, organ & tissue donation, research, serious threats to health or safety, military, national security, inmates, & workers' compensation.

  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An"example of this would be sending a bill for your visit to your insurance company for payment.
  • Healthcare operations include the business aspects of running our practice, such as conducting quality assessments and improvement activities. auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members. other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. lf we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of this day, this month, and this year we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We"reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.


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.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services. Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing i complaint For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W." Washington D.C. 20201 or call (202) 619--0257 or Toll-Free: 1-877-696-6775

Your information will be encrypted.