Patient History Update

The following questions are designed to update your health history, insurance, and personal information, and to make us aware of any changes regarding your appointments in our office:

Other than the responsible party, who else can bring the patient to their appointment(s), discuss financials, or schedule appointments?

To the best of my knowledge, the questions on this update form have been accurately answered. I understand that providing incorrect information can be dangerous to my health and that it is my responsibility to inform Byrne Orthodontics of any changes in my medical status. I also authorize Byrne Orthodontics to perform any necessary orthodontic services that I may need.

Patient Consent for the Use & Disclosure of Protected Health Information

I have read and received the Notice of Privacy Practices and hereby give my consent for Byrne Orthodontics to use and disclose health information (PHI) about me/my child to carry out treatment, payment, and healthcare operations (TPO).

I authorize the release of any information relating to this claim and understand that I am responsible for all costs of dental treatment.

I hereby authorize payment directly to Byrne Orthodontics of the group insurance benefits otherwise payable to me.