Patient Information Form

I AUTHORIZE THE DENTAL TEAM TO PERFORM THE NECESSARY SERVICES I MAY NEED.

I UNDERSTAND WHEN THE OFFICE SUMMITS A CLAIM TO MY INSURANCE I AM RESPONSIBLE FOR THE CO-PAYMENT AND DEDUCTIBLE ON THE SERVICES RENDERED AT THE TIME THEY ARE PROVIDED. IF FOR ANY REASON YOUR INSURANCE DENIES PAYMENT FOR DENTAL WORK ALREADY PERFORMED I
UNDERSTAND I AM RESPONSIBLE FOR THE REMAINING BALANCE.

WE REQUIRE A CREDIT CARD TO BE KEPT ON FILE FOR ANY REMAINING BALANCE DUE AFTER INSURANCE PAYMENT IS RECEIVED. PLEASE PROVIDE CREDIT CARD INFORMATION BELOW:

I DIRECTLY ASSIGN TO DR. CAROLYN DEVITO TO RELEASE
ALL INFORMATION MANUAL OR ELECTRONICALLY NECESSARY TO SECURE PAYMENTS OF BENEFITS.

I HAVE BEEN NOTIFIED OF THE PRIVACY POLICY OF THIS OFFICE AND UNDERSTAND THAT A COPY IS AVAILABLE UPON MY REQUEST.

GRANT PERMISSION TO THE DENTAL PRACTICE TO UPLOAD AND STORE CONFIDENTIAL PATIENT INFORMATION (INCLUDING ACCOUNT INFORMATION, APPOINTMENT, AND CLINICAL INFORMATION) TO THE SECURE WEB SITE FOR THE DENTAL PRACTICE. I UNDERSTAND THAT FOR THE SECURITY PURPOSES THE SITE REQUIRES USER AND PASSWORD TO ACCESS AND USE.