I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health care practitioners.
1. I understand that payment for dental services rendered is due the day the treatment is performed.
2. I understand that if financial arrangements are made they will be worked out prior to the start of treatment.
3. I understand that account balances of 60 days or more carry a service charge of 1.5 % per month on the unpaid balance.
4. I understand that if collection action is to be taken to collect payment from me I will be responsible for all the costs of such action-collection agency, attorney’s fees and court costs included. The parties agree that in the event that litigation is commenced to enforce this Agreement, that venue for said action shall be in Orange County, Florida.
IF YOU ARE COVERED BY INSURANCE:
5. I understand and agree that I am responsible for payment of all treatment fees on my account. If my insurance company fails to pay within 60 days, I will be responsible for the full amount at that time. I understand that after 60 days all insurance balances will be transferred to account balances due.
6. I understand and agree that the amount estimated to remain unpaid by insurance is to be paid by me at the time of treatment (co-insurance).
7. I understand that this office cannot make a totally accurate estimate of insurance benefits to be paid for me, since it does not have access to all insurance company records.
8. I understand that if this office refiles a claim that was initially denied by my insurance company, there will be a $25 charge to do so.
9. I understand that after the insurance company pays, there could be a balance still remaining to be paid by me and is due in full at that time.
10. I understand that this office does not provide long term financing but does utilize an outside financing agency that can be utilized for patient use.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected healthcare information, and other important matters about your protected health information. A copy of our Notice accompanies this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation. This will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this consent.
You may obtain a copy of our Privacy Practices, including any revisions of our notice at any time by contacting us at 905 E. Michigan St., Orlando, FL 32806 407-843-4091
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Our office will make every attempt to remind you of your appointments via phone, email and/or text.