Please take a moment to let us know about your health and dental history. So that we may serve you more effectively.
Please check one of the appropriate answers for each question below.
Please check any of the following that may apply
Do you have or have you had any of the following?
Are you allergic or have you reacted adversely to any of the following
I certify that the above information is complete and accurate, to the best of my knowledge.
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations such as quality reviews.
I have been informed that I may review the practice’s Notice of Privacy Practices (for a more complete description of the uses and disclosures) before signing this consent.
I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s).
I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.
Please list anyone whom you wish for us to share information with regarding treatment or financial matters below.
AUTHORIZATION TO RELEASE INFORMATION:
I hereby authorize SEDA Dental to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize direct payment of surgical/medical benefits to SEDA Dental for services rendered by him/her in person or under his/her supervision. I also understand that is my responsibility to pay the difference between PPO fee charged and the benefit paid by my insurance, in addition to any plan deductible, claim denials, and /or amount over my yearly maximum. I agree to accept financial responsibility for all procedures performed in this office and for any balances not covered by my insurance due to the reasons above described.
I certify that the information given by me in applying for payments is correct. I authorize the release of all records on request and that payment of authorized benefits are made on my behalf.
FINANCIAL RESPONSIBILITY: I understand payment is due in full when service is rendered, unless there is a signed payment agreement with SEDA Dental. SEDA Dental has the right to send all delinquent accounts to a third-party collection agency, which may result in penalties up to 30%.
DEPOSIT POLICY: A deposit of 50% of the treatment fee will be required in order to make your reservation for all appointments exceeding 30 minutes.