Patient Forms

Please correct the errors described below.

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment ( including direct or indirect treatment by other health care providers involved in my treatment)
  • Obtaining payment from third party payers ( e.g. my insurance company)
  • The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices,which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT INFORMATION

PATIENT EMPLOYMENT INFORMATION

SPOUSE EMPLOYMENT INFORMATION

I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance, for myself, or above named patient, unless other financial arrangements are approved.

I also agree to pay for all costs of collection, including attorney
fees, and court costs, should additional means of collection be required. In addition, my signature on this form is my acknowledged authorization for the Dr. to seek a Credit Report if Credit is extended.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HEALTH HISTORY UPDATE

HAVE YOU A HISTORY OF:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Dr. Grady Gibson DMD and Staff have my permission to contact me regarding my appointments and other dental information pertaining to me by text and/or email:

FINANCIAL OPTIONS AND PAYMENT ARRANGEMENTS

Taking care of you and your family is our highest priority. That is why, when it comes to talking about finances, our goal is to provide you with clear information regarding our dental fees and your payment options. At the onset of treatment, we will provide you with an estimate of the total fees expected. Please understand that this will only be an estimate. Treatment needs can change for a variety of unforeseen reasons. Whenever possible, we will inform you of any treatment changes that will affect your financial estimate.

When estimating insurance coverage, we must also stress the word estimate as dental benefits are determined by each patient's dental contract. Every patient's dental plan is different, and necessary dental services are not necessarily covered. Most dental plans are designed to assist patients with their dental expenses. Very few dental plans fully cover all dental services. If you bring a copy of your dental plan, our staff will be happy to help you interpret your dental benefits. Without a copy of your dental benefits plan, only an estimate can be provided based on what a "typical" dental plan provides. If your dental plan pays more than expected, and you have paid your expected portion, you will receive a prompt refund. If your dental plan pays less than expected, a balance due will be reflected on your monthly statement. If your dental plan later determined that you were not eligible for coverage, the balance becomes your responsibility.

Thank you for reviewing your payment options and indicating your choice of payment. We appreciate the confidence that you have placed in us ca ring for you and your family. We are available at any time to assist you with your account. Please feel free to contact us with any questions you have regarding the payment options listed below.

PAYMENT OPTIONS

I, name stated above, have chosen Plan(s) above and accept full responsibility for this account.

I understand that any insurance estimate given by this office is not a guarantee of actual insurance payment or coverage. I also understand that I am responsible for all charges incurred for dentistry performed upon me and my dependents. Any insurance claim not paid in full after 60 days will become my responsibility at that time.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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