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 the following:
Treatment (including direct or indirect by other healthcare provides involved in my treatment)
Obtaining payment from third party payers (e.g. my insurance company)
The day-today 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 the notice from time to time and that I may contact you at any time to obtain the most recent copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and discussed 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 anytime. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.
Arkansas Family Dental Office Policies
Office Financial Policy
Payment is due the day of service. As a service to our patients we will file your dental insurance for you. As long as your insurance can be verified, you will only be responsible for your estimated percentage of treatment on that day of service. We can only give and estimate of what insurance will pay, any remaining balance is your responsibility.
48 Hours Notice Policy
It is very important that we receive notice of a change in plans at least 48 hours in advance. This gives us the chance to schedule another patient in your place. If we do not have sufficient notice regarding a schedule change, we will be unable to care for another patient in need of our services.
Arkansas Family Dental is sure that you understand why we must have policies along these lines. It is our policy to charge a $30.00 missed appointment fee to any patient that cancels their appointment the day of the appointment.
I understand that by signing this agreement I am expected to adhere to the policies set forth within this notice.