• HIPPA AND DENTAL TREATMENT CONSENT

    Smile Experts Dental, 9570-A Burke Road, Burke, VA 22015

  • 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:

    • Treatment (including direct or indirect treatment by other healthcare 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 term 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 protect 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.

    • DENTAL TREATMENT CONSENT  

    • Please read and Initial the following. if you have ANY questions, please ask your doctor prior to initialing

      1. Preliminary Consent for Treatment 

      I understand I am having any or all of the following done today: Exam, Radiographs "X-rays, and Cleaning "Prophylaxis".

      2. Medications, Substances, and medical Conditions 

      I understand that antibiotics, analgesics "Pain medicines", anesthetics, Latex, and other substances can cause allergic reactions, resulting In redness and swelling of tissues, itching, pain, vomiting, and/or more severe allergic reactions. I have informed the dentist of any known allergies and/or medical conditions, including possible pregnancy.

      3. Changes to Treatment Plan

      I understand that during treatment it may be necessary to change or add procedures because of conditions found during treatment that were not evident during the initial examination. Some of these changes are but are not limited to, root canal therapy that is necessary following the placement of "deep fillings" or Crowns recommended after placement of "Lage Fillings". I authorize my dentist to make any changes and/or additions to my treatment plan as necessary.

      4. Dentist Benefits

      I understand that treatment that my dentist recommends is based on what he/she determines is best for my dental health, and not necessarily based on what an insurance plan will pay. Therefore I understand that my insurance (If any) may not cover all aspects of my treatment plan and. I will be financially responsible for any treatment not covered by the insurance plan. I understand the treatment plan proposed to me is an estimate of Insurance benefits and my actual coverage may differ due to frequency limitations, group coverage, incomplete information provided by my insurance company, etc. I also acknowledge that I am responsible for any balance remaining in the event that my insurance coverage is terminated for any reason.

       

      I understand dental treatment has potential risks and consequences. likewise, so does the refusal or denial of dental treatment. Untreated conditions may lead to pain, swelling, infection, tooth loss and/or other severe consequences. I understand that derricistry Is not an exact science and that no exact results can be assured or guaranteed. I have had the opportunity to have all of my questions answered by my dentist.

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