1. The undersigned hereby authorities Dr. Joanne Suarez Martinez and Associates to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Joanne Suarez Martinez and Associates to make a thorough diagnosis of my child's dental needs. I also authorize Dr. Joanne Suarez Martinez and Associates to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment.
2. I certify that my child is covered by (______________) Insurance Co. and I assign directly to Dr. Joanne Suarez Martinez all Insurance benefits, otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
3. To avoid a missed appointment charge of $50, we request that you cancel at least 24 hours prior to your child's scheduled appointment. We greatly appreciate your cooperation.
4. A $25 fee is automatically charged to your account for all returned checks.
5. I understand It is my responsibility to advise your office of any charges in the information contained on these forms.
Patient Acknowledgement of Receipt of Dental Materials Fact.
Purpose of Consent: By signting this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available upon request.
You may obtain a copy of our Notice of ePrivacy Practices, Including any revisions of our Notice, at any time by contacting:
Pediatric Smiles of Orange Dental GroupJoanne Suarez Martinez, D.D.S.26711 Aliso Creek Road, Suite 200-C Aliso Viejo, CA 92656Ph: (949) 349-0303
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
I have had full opportunities to read and consider the contents of this Consent Form and notice of Privacy Practices. I understand that, after signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activies and healthcare operations.
You may Refuse to Sign this Acknowledgement
We attempted to obtain written acknowledgement of receipt of our Privacy Practices , but acknowledgement could not be obtained because:
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.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: