HIPAA CONSENT FORM AND PRIVACY POLICIES
PLEASE READ THE FOLLOWING CAREFULLY:
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 health information, and of other important matters about your protected health information. A copy of our Notice can be found at the front desk when asked. 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. If you decide to pay for your treatment in full on the date of service and do not want your insurance to be billed, you have the right to request not to disclose treatment information for this service to a health plan. If applicable, a patient has the right to an Electronic copy of their records if they prefer. YOU MAY OBTAIN A COPY OF OUR Notice of Privacy Practices, INCLUDING ANY REVISIONS OF OUR NOTICE, AT ANY TIME, BY CONTACTING US.
RIGHT TO REVOKE:
You will have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent 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 TO CONTINUE TREATING YOU if you revoke this consent.
Authorization and Release of Records
I authorize Larsen Family Dentistry to release any information, including the diagnosis and the records of any treatment or examination
rendered to me or my child during the period of such dental care, to third party payers and/ or health practitioners. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree to allow Larsen Family Dentistry to leave messages concerning my appointments and/ or results on my answering machine or with family members.
- Payment is expected at the time the service is rendered. We will accept Cash Personal checks The following Credit Cards: Visa MasterCard DiscoverCard
- Non-insured patients are expected to make payment in full on the day the service is rendered, unless definite arrangements have been made with our office manager PRIOR TO TREATMENT.
- Patients with dental insurance are expected to pay the portion of the total fee not covered by their insurance on the day of service. The “Patient Portion” is ONLY an estimated dollar amount. DUE TO HIPAA, WE ARE NOT ABLE OR ALLOWED TO GATHER ANY INSURANCE INFORMATION FROM A 3RD PARTY. IT IS THE RESPONSIBILITY OF THE PATIENT TO HAVE FULL INFORMATION AT THE DATE OF SERVICE OR THE PATIENT WILL BE EXPECTED TO PAY THE FULL AMOUNT. AS A COURTESY, our office will file your claim with your insurance company, and initiate correspondence with the purpose of getting you the maximum coverage your insurance will allow; however, if we do not receive payment from your insurance company within 60 days, the payment becomes your responsibility.
- It is the PATIENT’S responsibility to know and understand his/ her insurance coverage. Larsen Family Dentistry will be happy to give you the number of your insurance company to contact them with further questions.
- The patient is ALWAYS responsible for seeing that the ENTIRE FEE is paid in full.
- If payment is not taken care of by the insurance or the patient within 90 days, there will be a fee added to the account, and the account will be sent to Collections.
- AS A COURTESY, Larsen Family Dentistry gives reminders of the patients’ appointments via mail and phone. However, it is the patient’s responsibility to remember their appointments and be on time. It is not the responsibility of the office if the patient does not receive the reminders and forgets his/ her appointment, which will result in a failed appointment fee.
To achieve the highest level of patient care and time management, our office requires appointment changes to occur within the office hours (7:00am to 3:00pm) the day before (24 hours) the appointment date. Failure to do so will result in a $50.00 failed appointment fee.
I authorize Larsen Family Dentistry to use my phone number and email address to send me healthcare and marketing messages, e.g. appointment reminders, new services, events, or special offers. I know I have the right to opt out or unsubscribe whenever I choose.
AS A PATIENT/ RESPONSIBLE PARTY AT LARSEN FAMILY DENTISTRY I UNDERSTAND AND AGREE TO THE ABOVE POLICIES
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and health care operations.