Consent for Treatment
Use of Images
Your photos and x-rays are part of your diagnostic and clinical record and are considered to be protected health information under federal HIPAA Privacy Laws.
We make use of radiographs (x-rays), photographs, and digital images. These images may be used for diagnosis, documentation, reference, teaching, and research publication. Some cases that present exceptional results, particularly remarkable smiles, or interesting situations may be utilized for demonstration, education or advertising to potential and existing patients in our office either in print media, social media, television, on digital media and on our webpage. In some instances, you may be recognizable in some of these images.
By acknowledging and signing this form, you are authorizing us and releasing us from any liability resulting from the use/release of such images. Your authorization and release to use images will in no way affect the quality of your results in our office. We do our best to provide exceptional dentistry to all patients.
Transmission of Protected Health Information by Email, Text Message & HTTPS Protocol
I consent to transmit the following protected health information related to my health records and health care treatment - information related to the scheduling of meetings or other appointments, information related to billing and payment, completed forms, including forms that may contain sensitive confidential information, information of clinical nature, including discussion of personal material relevant to my treatment, my health record, in part or in whole, or summaries of material from my health record.
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this authorization at any time in writing.
We are happy to bill your insurance as a courtesy. However, the patient receiving service (or the responsible party) is ultimately responsible for all fees incurred.
We require you to pay the “patient portion” at the time of service and require patients scheduling over an hour of time with the Dentist to pay 50% of the patient portion prior to their appointment, this may include a deductible, co pay, and/or a percentage of each procedure.
If your insurance has not made payment in full within 2 months of treatment, you are responsible for paying the balance, and your insurance company will then reimburse you. We accept cash, checks, VISA, and MasterCard. We also offer financing through Care Credit and Lending Club.
If a check is returned for non-sufficient funds, a returned check fee of $30 will be added to your account. Past due accounts are subject to finance charges. All accounts past 90 days are also subject to small claims court or an outside collections agency which may impact your credit score.
For patients receiving sedation during their visit, payment is required 48 hours prior to treatment.
Receipt of Privacy Practices
I consent to transmit the following protected health information related to my health records and health care treatment - Information related to the scheduling of meetings or other appointments, information related to billing and payment, completed forms, including forms that may contain sensitive confidential information, information of clinical nature, including discussion of personal material relevant to my treatment, my health record, in part or in whole, or summaries of material from my health record.
We consider the time set aside for your appointment to be your reserved time. In order to allow all patients experience the best possible appointment arrangement, please recognize the following cancellation policy and fee associated with our practice.
1. Confirmation of your appointment
For appointments scheduled more than 48 hours in advance, a confirmation via text, email, online chat or phone is required prior to your appointment.
2. If you need to cancel an appointment
If you are unable to keep your appointment, please let us know immediately so that we are able to offer your appointment time to another patient. At the discretion of My Friend’s Dentist, appointments cancelled less than 24 hours before their scheduled time will be considered a missed appointment and a $50 cancellation fee, not covered by insurance, will be charged.
3. If you’re running late for an appointment
We realize that traffic, weather or other unforeseeable circumstances can play a role in being late for an appointment. We accommodate appointments up to 10 minutes late without rescheduling.
4. If you need to miss an appointment
We understand that last minute changes in your schedule or emergencies may arise that cause you to miss your appointment. However, missing 3 or more appointments within a year may result in a formal dismissal from our office. This policy ensures that patients who keep their appointments will be able to occupy timeslots that are available.
Medical Information Release (HIPAA Release)
Complete this form to authorize the release of information related to your treatment, appointments, insurance claims or financial information to another person.
This information may be released to: