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HIPAA/Financial - For New Patient(s) and/or 18+
COMPLETE FORM IF:
NEW TO PRACTICE -patient(s) under 18 years old, parent or legal guardian must complete and sign form.
PATIENT IS 18 YEARS OR OLDER - patient must complete and sign form.
First Name
Last Name
Additional Patient(s) Name(s):
PRIVACY NOTICE: https://pediatricdentistns.com/wp-content/uploads/2025/01/privacy_notice_display_copy.pdf I hereby acknowledge that I received the Notice of Privacy Practices from Pediatric Dentistry of Northbrook, Ltd.
CONSENT FOR TREATMENT: Pediatric Dentistry of Northbrook, Ltd, the dentists, employees, or designees will provide dental services, diagnostic procedures, and medications as deemed necessary or advisable. I hereby consent and authorize treatment
AUTHORIZATION TO DISCUSS DENTAL CARE AND ACCOUNT INFORMATION: It is the policy of this practice to contact our patients to confirm or reschedule appointments, or leave information regarding results or account. We may text, email, leave a message on your home/cell voicemail or speak with whoever answers the phone. I understand the terms and authorize the practice to disclose the information as mentioned.
IF YOU ARE THE PATIENT AND OF AGE 18+, may we speak to someone other than yourself about your care? If yes, please indicate:
RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS: I authorize Pediatric Dentistry of Northbrook, Ltd to obtain and release any pertinent information needed for my care to other providers or insurance carriers involved. I understand that I am responsible for any fees for services rendered for myself and/or my children. I hereby authorize Pediatric Dentistry of Northbrook, Ltd to furnish information to my insurance carrier concerning all conditions. I hereby assign to Pediatric Dentistry of Northbrook, Ltd payments made by my insurance carrier. I consent to my information being used as described.
FINANCIAL RESPONSIBILITY: You are financially responsible for all charges for services rendered by Pediatric Dentistry of Northbrook Ltd. Payment is due at the time services are rendered. Treatment will be based on necessity and professional recommendation. If dental insurance information has been provided, claims will be submitted as a courtesy and at no additional cost. You will be asked to pay estimates based on insurance coverage and deductible; however final coverage is determined by insurance. It is your responsibility to contact the insurance with any questions regarding benefits or to resolve any issue(s) regarding coverage/payment for services provided. Unpaid charges over 60 days old will incur a processing fee of $20.00 monthly. In the event that your account is placed with an agency for collection purposes, you are responsible for 40% of the collection agency fees, in addition to all court costs, filing fees, and attorney fees, should the account require litigation. I understand and agree with all mentioned above.
I hereby acknowledge that I have received a copy of this offices Notice of Privacy Practices. I may refuse to sign this acknowledgement. To obtain a paper copy I may request it from the office or the website.
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