ASSIGNMENT, RELEASE, AND ACKNOWLEDGEMENT: I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balance due. I also authorize to release any information required for this claim. In addition, in consideration of the service rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.
Additionally, my signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: 1) Provide and coordinate my treatment among number of health care providers who may be involved in that treatment directly and indirectly. 2) Obtain payment from third-party payers for my health care services. 3) Conduct normal health care operations such as quality assessment and improvement activities.
I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
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.