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Black Warrior Dental Center

1604 Greensboro Ave,
Tuscaloosa, AL 35401
(205) 764-1529

( * mandatory to fill )
  •  Policy Holder
  •  Responsible Party
Responsible Party (If Someone Other than Patient)( * mandatory to fill )
  •  Responsible Party is also a policy holder for patient
  •  Primary Insurance Policy Holder
  •  Secondary Insurance Policy Holder
Patient Information( * mandatory to fill )
  •  I would like to receive correspondences via e-mail
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  •  Full Time
  •  Part Time
  •  Retired
  •  Full Time
  •  Part Time
Section -3( * mandatory to fill )
Primary Insurance Information( * mandatory to fill )
SECONDARY INSURANCE INFORMATION( * mandatory to fill )
Medical History( * mandatory to fill )

 

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you'll recene. Thank you for answering the following questions.

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  •  Pregnant/trying to get pregnant?
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  •  Pencillin
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  •  Acrylic
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  •  Local anesthetics
  •  Other
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FINANCIAL AGREEMENT ( * mandatory to fill )

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. All charges you incur for any treatment that is provided are your responsibility regardless of your insurance coverage. We will always recommend treatment based upon your dental needs, not based on insurance coverage, which can be inadequate with some dental plans. Dental insurance is a benefit used to assist you, not to dictate necessary treatment. As We Work with you to reach your optimum oral health, we do require that the estimated copayment for treatment be paid at the time of service. This is the portion of our fees that your insurance coverage does not assist you with. Timely payment of patient estimated co-payments ensure that we can keep our administrative costs low, resulting in lower fees for our valued guests. 

Your estimated co-payment may be adjusted after the time of treatment depending upon the final reconciliation of insurance payments. Our practice accepts cash, personal chocks, MasterCard and Visa. Third party extended payment financing is also available upon request and approval. Returned checks and balances older than 60 days will be subjected to collection fecs and finance charges at the rate of 1.5% per month (18% annually). Additionally, our practice will charge you for missed reservations and reservations cancelled with less than 24 business hours' notice.

Our practice will accept an assignment of benefits from your insurance company and it is important to understand that the agreement regarding your dental benefits is between you, your employer, and your insurance company. Although we are willing to submit dental claims on your behalf, we do not accept responsibility for the outcome of the transaction Completing insurance forms is a courtesy we extend in an effort to save you time and facilitate payment to our practice from your insurance Company. By having our practice process your insurance forms, it is important that you understand that this does not eliminate your financial obligation.

Insurance payments are received within 30-60 business days from the time of billing. If your insurance company has not made payment to our practice within 60 days, we will ask you to pay the entire balance at that time and you will be responsible for seeking reimbursement from your insurance company.

 

Our practice does not guarantee that your insurance company will assist you with payment for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time. Our practice will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. It is your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice.

Cancellations and rescheduling dental visits 

Our officer does require 24 business hours' notice to cancel/reschedule existing visits with us. If we do not receive such notice, there is a charge of $75 for any missed visits.

I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS OF THE FINANCIAL AGREEMENT AND I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE PRACTICE.

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CLIENT RIGHTS AND HIPAA AUTHORIZATIONS( * mandatory to fill )

The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA"). 

1. Tell your provider if you do not understand this authorization, and the provider will explain it to you.

2. You have the right to revoke or cancel this authorization at any time, except (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to provider at the following address (insert address of provider). 

3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment payment, enrollment or your eligibility for benefits. However, you may be required to complete this authorization form before receiving treatment if you have authorized your provider to disclose information about you to a third party. If you refuse to sign this authorization, and you have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a patient in their practice. 

4. Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.

5. You may inspect or copy the protected dental information to be used or disclosed under this authorization. You do not have the right of access to the following protected dental information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act ("CLIA”) prohibits access, or information held by certain research laboratories. In addition, our provider my deny access if the provider reasonably believes access could cause harm to you or another individual. If access is denied, you may request to have a licensed health care professional for a second opinion at your expense.

6. If this office initiated this authorization, you must receive a copy of the signed authorization. 

 

7. Special Instructions for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes." All Psychotherapy Notes recorded on any medium by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client's medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session of a group, joint: or family counseling session and that are separate from the rest of the individual's medical records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Except for limited circumstances set forth in HIPAA, in order for a medical provider to release "Psychotherapy Notes" to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other dental records. 

8.You have a right to an accounting of the disclosures of your protected dental information by provider or its business associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request. The provider is not required to provide an accounting for disclosures: (a) for treatment, payment, or dental care operations; (b) to you or your personal representative; (c) for notification of or to persons involved in an individual's dental care of payment for dental care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (I) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody, or (b) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to dental oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.

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