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 a third party payer (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 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 that I revoke this consent is not affected.

When our office books your appointment, we set aside a dedicated chair and time slot just for you! We ask that if you must reschedule your appointment, please provide us with at least 24 hours’ notice. We send multiple reminders over text and email. If you do not receive reminders and would like to, please be sure to check the spam folder of your email. If you still do not see the emails, please tell the front desk so we can make those arrangements for you.

There will be a $50.00 charge for not showing up for your scheduled appointment or for canceling less than 24 hours before your scheduled appointment. (If you have an emergency, you will not be charged, just please make us aware.)

This policy enables us to better utilize available appointments for our patients in need of dental care, thank you.

Thank you for choosing our office. As your dentist, we are committed to providing you with quality care. In order to reduce confusion and misunderstanding we have adopted the following financial policy.

1. Payment is due at time of service.
   
   
2. We accept cash, personal checks, MasterCard, Visa, American Express, Discover, and CareCredit.
   
   
3. Services rendered for dependent children are to be paid by the parent who brings the child to the office for treatment, regardless of marital status or divorce status.

1. We are out of network provider. We do not let insurance companies dictate the quality of care we provide.
   
   
2. Your insurance policy is a contract between you and your insurance company. As a courtesy we will file your insurance claim for you.
   
   
3. All insurance plans are not the same and do not cover the same services. In the event your insurance determines a service to be not covered, you will be responsible for the complete charge. Payment is due at time of service.
4. All payments are due at time of service. An additional $25.00 will be applied to your account if payment is not received to cover the cost of sending out statements.