To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status.

I hereby give you permission to release all dental records to:

Van Praag Cosmetic & Family Dentistry 

11 Yorkshire Street, Suite 101
Asheville, NC 28803
828-378-1080
office@pvpdds.com

Patient Rights:

• I have the right to revoke this authorization at any time.
• I may inspect or copy the protected health information to be disclosed as described in this document.
• Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
• Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may not longer be protected by federal or state law.
• I have the right to refuse to sign this authorization and that my treatment will not be conditional on signing.

I understand that I have certain rights to privacy regarding my Protected Health Information (PHI). These rights are provided under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes safeguards for the privacy and security of my health information.

What this means: There are rules and restrictions on who may view or be notified of your Protected Health Information (PHI). These restrictions do not include the normal exchange of information necessary to provide you with healthcare services. HIPAA provides certain rights and protections to you as the patient, and we balance these protections with our goal of providing you with quality professional care and efficient administrative service.

Our office has adopted the following policies:

• Patient information will be kept confidential except as necessary to provide services or to ensure that administrative matters related to your care are handled appropriately. This may include sharing information with other healthcare providers, laboratories, and health insurance payers as necessary for your treatment, payment, or healthcare operations. In the normal course of providing care, patient records may be temporarily located in administrative areas such as the front desk or treatment rooms; however, they will not be available to individuals other than authorized office personnel.
• Our office may contact you to remind you of scheduled appointments. These reminders may be provided by telephone, voicemail, email, text message, U.S. mail, or other methods convenient for the practice unless you request otherwise.

• The practice utilizes third-party vendors and service providers in the course of business operations. These vendors may have limited access to PHI but are required to comply with HIPAA confidentiality and security requirements.

• You understand and agree that government agencies or insurance companies may inspect the office and review documents, including PHI, as part of their regulatory or administrative duties.

• If you have any concerns or complaints regarding privacy practices, you agree to bring them to the attention of the doctor or office manager so that we may address them promptly.

• Your confidential health information will not be used for marketing or advertising purposes without your written authorization.

• You have the right to access and request copies of your health records in accordance with applicable federal and state laws.

• The practice reserves the right to change, modify, add, or remove provisions of this privacy policy as permitted by law in order to better serve the needs of both the practice and its patients.

• You have the right to request restrictions on certain uses or disclosures of your PHI and to request confidential communications. While we will consider all reasonable requests, we are not required to agree to restrictions that would interfere with the provision of care or business operations.

• Federal law provides additional protections for certain health information, including records related to substance use disorder diagnosis or treatment. Such information will not be disclosed without the patient’s written consent except as permitted by law under 42 CFR Part 2.

I acknowledge that I have been offered or provided a copy of the practice’s Notice of Privacy Practices and understand that I may request a copy at any time. I understand that this consent will remain in effect from this time forward unless I revoke it in writing, except to the extent that the practice has already taken action in reliance on this consent.

At Van Praag Cosmetic & Family Dentistry, our goal is to provide high-quality dental care with transparency and fairness. To maintain this effort, we ask that you review and sign the following statement prior to receiving treatment.

Payment Policy

Treatments completed in a single visit, such as cleanings, exams, and basic fillings, will follow standard payment arrangements, including insurance processing.

Major restorative procedures requiring multiple visits, such as crowns, bridges, dentures, and implants, will require:

• 50% of the total treatment fee due at the first appointment.
• The remaining balance is due at the final appointment.
• Please note: If payment is not made, your final appointment may be rescheduled.

Insurance Information

Your insurance is a contract between you and your insurance company. As a courtesy, our office will file your insurance claims on your behalf. Although we are not in network with any dental insurance providers, we are happy to work with patients who have out of network benefits. Please note:

• Insurance estimates are not guarantees of payment.
• Payment is due according to our financial policy regardless of insurance coverage.
• Any remaining balance not covered by insurance is the patient’s responsibility.

Our goal is to make your experience as seamless and stress-free as possible, and we are here to help you navigate your insurance benefits to maximize your coverage.

Payment Methods

We accept cash, check, debit/credit cards, and financing options such as Affirm and CareCredit. Please speak with our front desk for payment assistance or questions. We appreciate your understanding and cooperation. If you have any questions about this policy or your treatment estimate, please ask a member of our team – we are happy to review it with you.

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY STATED ABOVE.