Notice of Privacy

Please correct the errors described below.

We are legally required to maintain the privacy of your health information. You have the right to look at copies of your health information. (Please read attached copy of our Privacy Practice).

I give permission to Bloor Dentistry to discuss my dental care with:

Assignment and release for insurance billing:

I certify that I, and or my dependent(s), have dental benefit coverage and assign directly to Dr. Priti S. Bloor all of the insurance benefits, if any, otherwise payable to me for services rendered. I understand I am responsible for all charges paid by insurance or not. I authorize the use of my signature on all insurance submissions. The above name dentist may use my health care information and may disclose such information to the insurance company and their agents for the purpose of obtaining payment for service and determining insurance benefits for the benefits payable for services.

Parental Consent and Responsible Party Statement

Parental consent is required for any unaccompanied minor child under the age of 18. We will treat unaccompanied minor children as long as parent/guardian is available by phone and the parent/guardian has signed the Permission to Treat Contact Form and Medical History form prior to appointment.

give permission to Bloor Dentistry to perform all dental treatment on my child,

regardless of my presence in the office. I understand and agree to Bloor Dentistry's treatment of minor consent form. I agree to pay for all services provided to my child.

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