Mayfair Family Dentistry

Patient Information

Spouse Information

Dental Insurance Information

By clicking "I Agree", you indicate you have read and acknowledge the policies/procedures below.

Financial

I authorize payment directly to the dentist from the insurance benefits. It is assumed that payment for all fees will be received at the time of service unless prior arrangements have been approved. In case of default of this account, I understand that I may be sent to collections to render payment.

HIPAA / Authorized Individual

I give the following person access to my private information at this office for appointment discussion, health information, and discussion regarding past, current and future treatment information:

For Minor Children: If I am unable to bring in my child for treatment, I authorize the following person to accompany my child and make decisions for their treatment in the event of an emergency:

**AUTHORIZED PERSON MUST SHOW PHOTO ID AT THE TIME OF THE VISIT**

• I understand that Mayfair Family Dentistry may take photos of my teeth/face for the documentation of my care or consulting with other providers for my care to include: medical doctors, dental professionals, labs.
• It is the policy of this office to dismiss patients from practice that have two appointments in a year that are confirmed and failed. We understand that situations happen out of your control. Dr. Holmes may make exceptions to this policy as needed.

Dental History Form

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform the office of any changes in my medical status. I also authorize the dental staff to perform the necessary dental services I may need.

HIPAA Notice of Privacy Practices

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office (or from our website).

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare
operations. You also signify that you have received a copy of our Notice of Privacy Practices.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Mayfair Family Dentistry.

If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form: