HIPAA Consent Form

Excellence in Dentistry - WI
1001 North Sherman Avenue - Madison, WI 53704 - 608-240-1001

Excellence in Dentistry - WI
226 West Cottage Grove Rd - Cottage Grove, WI 53527 - 608-839-4554

I acknowledge that I have received a copy of the Notice of Privacy Practices for Excellence In Dentistry. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health information that might occur in my treatment, payment for services, or in the performance of the oce health care operations. The Notice of Privacy Practices also describe my rights and the responsibilities and duties of Excellence In Dentistry Group with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility. Excellence In Dentistry reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my rst visit after the revisions become effective. I may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specically authorize disclosure of my protected health care information to the persons indicated below.

MY SIGNATURE BELOW ACKNOWLEDGES I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES. ALL OF MY QUESTIONS HAVE BEEN ANSWERED AND I UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS ACKNOWLEDGEMENT AND/OR CHANGES IN THE ADDITIONAL DICLOSURE AUTHORITY AT ANY TIME.

GENERAL CONSENT AGREEMENT

CONSENT TO TREATMENT

I consent to receive dental services, including examination, dental prophylaxis (cleaning) and routine llings from Excellence In Dentistry (the “PRACTICE” I understand that the initial visit may require radiographs to complete the examination, diagnosis and treatment plan. I understand I will be provided a treatment plan for necessary services; however, I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to my treating dentist to make any/all changes and additions as necessary. I further understand that clicking, popping, and pain in the jaw joint may occur as a normal part of treatment; however, should the discomfort become intolerable, I may be referred to a specialist for treatment, the cost of which is my responsibility.

TREATMENT OUTCOMES

I understand that the practice and my treating dentist cannot guarantee treatment outcomes. I am responsible for reviewing the treatment plan and asking any questions I may have prior to receiving treatment. I have the right to accept or reject treatment recommended by my treating dentist. By consenting to my dentist’s treatment plans, I acknowledge that I accept known risks and complications of such treatments. It is my responsibility to fully inform the dentist of my medical history, all medications or other drugs that I am using and otherwise truthfully answer all questions related to my care. It is also my responsibility to follow my dentist’s pre- and post-treatment instructions and oral care instructions. I acknowledge that failure to comply with these requirements may increase the chance of poor treatment outcomes.

CONSENT TO PHOTOGRAPH

I understand photographs, videotapes, digital and/or other images may be made/recorded for identication, treatment and payment purposes. These will be part of my record and will not be used for any marketing or other purposes. I will specically authorize in writing any other use or disclosure of any image or recording.

CONSENT TO ELECTRONIC PRESCRIBING

I authorize an electronic prescribing network to release my medication rell history to the practice for the purpose of continued treatment.

CONSENT TO SCHEDULING AND APPOINTMENTS

I understand photographs, videotapes, digital and/or other images may be made/recorded for identication, treatment and payment purposes. These will be part of my record and will not be used for any marketing or other purposes. I will specically authorize in writing any other use or disclosure of any image or recording.

PAYMENT FOR SERVICES

I understand that I am responsible for all charges for the care I receive. If I do not have dental insurance coverage, I will pay all amounts for which I am responsible in full, in advance of treatment. It is my responsibility to provide accurate and up-to-date information regarding my dental insurance coverage. I agree that payments from my dental plan may go directly to the practice. If I should receive the payments, I understand that I will be responsible for immediately paying such amounts to the practice. Depending on the type of coverage I have, my responsibilities are as follows:

IN NETWORK: If my treating dentist is in-network with my dental insurance plan, I will be billed pursuant to the terms of my insurance policy and my dentist’s contract with the insurer. Even when the practice and my treating dentist are a participating provider with my insurance, I understand that the practice may hold me responsible and collect all charges in any one of the following situations:

• When I choose to have a service that my dental plan covers but I do not obtain the required re ferral or prior authorization from my health plan. 

• When I choose not to use my dental plan and agree to pay for se rvices myself.

• When I receive services that are not covered under my dental plan

OUT OF NETWORK: If my treating dentist is not a participating provider with my insurance, I will be required to pay for all treatment in full, in advance. The practice may le for insurance coverage as a courtesy and apply anything they pay towards my account. If payment from my insurance company results in an overpayment on the account, I will be reimbursed by the practice.

ALL PAYORS: Regardless of whether my treating dentist is participating provider, I will be responsible for any deductibles, co payments, the costs of uncovered services and any other part of the bill that my dental plan says I must pay. If for any reason I do not pay, in full, the amounts I owe the practice, I will also reimburse the practice for all costs of collection, including legal fees and a 25% collection fee of the total amount submitted to the collection agency. I also agree the practice may charge me interest equal to 2% monthly on all balances that have been outstanding for thirty (30) days or more.

RELEASE OF INSURANCE BENEFITS

I agree to be responsible for all charges for dental services and materials not paid by my dental benet plan, unless prohibited by law or the treating dentists or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to Excellence In Dentistry Group’s use and disclosure of my protected health information to carry out payment activities in connection with insurance claims. I hereby authorize and direct payment of the insurance benets otherwise payable to me, directly to Excellence In Dentistry Group and its partnered aliates.

MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE READ THIS CONSENT AGREEMENT AND AGREE TO THE STATED ITEMS AS THEY HAVE BEEN OUTLINED. I HAVE BEEN GIVEN THE OPPORTUNITY TO HAVE MY QUESTIONS ANSWERED AND UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS AGREEMENT AT ANY TIME. I FURTHER ACKNOWLEDGE THAT I MAY REVOKE MY CONSENT TO ALL OR ANY PART OF THIS CONSENT AGREEMENT AT ANY TIME BY DOING SO IN WRITING.