FINANCIAL AGREEMENT
Our mission is to provide you with the finest dental care available today. Fine dentistry is an investment and our goal is to help make this investment possible for you. Payment is due in full at the time services are rendered. We gladly process and file all necessary documentation for patients with insurance as a courtesy in a prompt manner. The benefit company will reimburse you directly. We offer many flexible payment options:
- 5% discount for cash or check pre-payment due the day we reserve your appointment for amounts over $2,000
- 3% discount for credit card pre-payment due the day we reserve your appointment for amounts over $2,000
- Extended payment plans are available with up to 18 months interest free financing
- Illumisure Membership Program
I understand that I am financially responsible for all charges regardless of my insurance coverage and that it is my responsibility to be familiar with the details of my plan. I understand the above payment options and am aware that all financial arrangements must be made prior to scheduling treatment.
HIPAA
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 carry out:
- 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 terms 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 protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to those requested restrictions. However, if you do agree, you are then bound to comply with his 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. I herby give my consent to Dr. Angela Cotey, DDS to use my dental photograph(s), testimonial, video, slides, models or any other image, with or without my name, for educational purpose and in the use of promoting dentistry.