Form

Authorization for Disclosure, General Consent, & Insurance Release

AUTHORIZATION FOR ADDITIONAL DISCLOSURE:

I authorize the following individuals to have access to my health information.

1. Name

Relationship

2. Name

Relationship

3. Name

Relationship

CONSENT:

I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employ any such assistance as they deem appropriate.

I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others whom the doctor deems appropriate.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins.

I understand it is a policy of this office to leave brief messages to confirm dental appointments, inform me of records received from my insurance company, and other dental related issues.

I understand that my dental appointment has been reserved especially for me or my family member and implies an obligation to be present. I understand that to change or cancel my appointment I must do so with at least 24 hours notice to avoid a cancellation fee.

INSURANCE RELEASE AND AUTHORIZATION:

1) Insurance Company:

Group #

Member or Subscriber ID

2) Insurance Company

Group #

Member or Subscriber ID

I certify that the above insurance information is correct and in force. I am aware that it is my responsibility to read and understand my own dental insurance policy, including benefits, limitations and exclusions. I understand that filing of insurance claims is my responsibility and may be provided by this office as a service to me. I understand that:

My dental benefit program is a contract between me, my employer and the insurance company. My dentist is NOT a party to that contract.
My dentist’s fees may not necessarily be covered in full by the maximum allowance determined by my insurance.
Not all dental services are a covered benefit in all insurance contracts.
Services by this office are rendered independent of insurance reimbursement.
I am responsible to this office for all fees for services rendered to me.
This release authorizes facilitation of the billing and reimbursement, direct to the doctor, of insurance benefits under which I am entitled.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date