Jeff Martin D.D.S & William Taylor D.D.S.

TREATMENT CONSENT

• I voluntarily and knowingly request and consent to the services, treatment, and/or procedures recommended by the dentist and to all diagnostic methods deemed appropriate by the dentist, which may include, but not be limited to, x-rays, study models, imagery, and other aids.
• I authorize the dentist to perform all such services, treatments, and/or procedures and to utilize all such diagnostic methods. Further, I acknowledge and understand that the dentist may engage the assistance of others in performing such services, treatments, and/or procedures and in utilizing such diagnostic methods.
• I understand that the practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the services treatment, procedures, and/or diagnostic methods that have been recommended.

FINANCIAL CONSENT

• I understand and acknowledge that I am fully and completely responsible for the payment of all costs associated with the services, treatments, procedures, and/or diagnostic methods performed and utilized by the dentist and others, and that services are due payable when rendered unless financial arrangements have been made in advance.
• I understand that all returned checks will be subject to a $25.00 returned check fee.
• I understand that any account balances that remain unpaid for 90 days from the date of service shall accrue interest at the rate of 18% (annual rate) and may be referred to a collection company or attorney. In the event this occurs, I understand that I will be liable for collection costs. Further, in the event any unpaid account balance is referred to an attorney for collection, I also agree to be responsible for all costs and reasonable attorney’s fees incurred in connection therewith. I also consent to be contacted by the dentist and any agent of the dental office, or any collection agency (or agent thereof) or attorney to whom an unpaid account balance has been assigned or referred by mail at any address that I provide to the dental office and/or by facsimile, email or phone number (whether a cell phone or landline).

INSURANCE-RELATED CONSENTS & BENEFITS ASSIGNMENT

• I acknowledge that it is my responsibility to provide the dentist with my current insurance or managed care information and any changes thereto.
• As a courtesy to me, the dental office will bill my insurance company or managed care company, and I acknowledge that I will remain liable for any and all amounts not paid by the insurance company or managed care company for any reason (including but not limited to the insurance company or managed care company declining coverage after initially approving it) or if the insurance company or managed care company fails for any reason to reimburse the dentist.
• I acknowledge that any insurance coverage or managed care benefit that I may have is based on a contract between my insurance company or managed care company and myself, my spouse, and/or my employer. The dentist is not a party to this contract, and the services, treatments, procedures, and /or diagnostic methods are provided to me. Therefore, I acknowledge that I am fully responsible for the payment of all sums owed to the dentist for the series, treatment, procedures, and/or diagnostic methods provided to me.
• I consent to the dentist’s use and disclosure of my health information to my insurance company or managed care company and any agent thereof.
• I hereby assigned to the dentist all of the insurance and managed care benefits due to me for the services, treatment, procedures, and/or diagnostic methods provided to me, and I authorize my insurance company and/or Managed Care Company to make payment directly to the dentist for the costs associated therewith.

HIPPA NOTICE & CONSENT

• I consent to the use or disclosure of my protected health information by Martin-Taylor Dentistry PLLC for the purpose of diagnosing or providing treatment to me, obtaining payment for my healthcare bills and laboratory bills, referring my care to outside specialists when necessary, or, to conduct healthcare operations. I understand that diagnosis or treatment of me by Martin-Taylor Dentistry PLLC may be conditioned upon my consent, as evidenced by my signature on this document.
• I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Martin-Taylor Dentistry PLLC is not required to agree to the restrictions that I request. However, if Martin-Taylor Dentistry PLLC agrees to a restriction that I request, the restriction is binding on the practice and the staff.
• I have the right to revoke this consent, in writing, at any time, except to the extent that Martin-Taylor Dentistry PLLC has taken action in reliance on the consent.
• My “protected health information” means the information, including my demographic information, collected from me and created or received by my dentist, another healthcare provider, a health plan, my employer, or a healthcare clearinghouse. This protected health information related to my past, present, or future physical or mental health or condition and identified me, or there is a reasonable basis to believe the information may identify me.
• I understand that I have the right to review the Martin-Taylor Dentistry PLLC Notice of Privacy Practices prior to signing this document. Martin-Taylor Dentistry PLLC Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of dental care operations by Martin-Taylor Dentistry PLLC. The Notice of Privacy Practices also includes and describes my rights and Martin-Taylor Dentistry PLLC’s duties with respect to my protected health information.
• Martin-Taylor Dentistry PLLC Notice reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.