Cattafesta Family & Cosmetic Dentistry
2579 John Milton Drive Suite 350 ,Herndon, VA, 20171(703) 214-3490
What is the goal you have for your
Have you ever had
Check all that apply
Have you experienced
What don't you like about your teeth?
How often do you
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
I, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
Please read carefully and sign to acknowledge understanding and agreement
Thank you for choosing us as you dental care provider. We are committed to providing you with the best dental care available.
Available Payment Options.
You can choose from ~ Cash, Check, Visa, Mastercard, American Express
We offer a 5% courtesy adjustment to patients who pay for their treatment, at the time of Scheduling your next appointment.
CareCredit payment plan option, ask us for detailed information.
Patients Without Insurance.
Cancellation/No Show Policy.
I hereby authorize payment to
by the group insurance, otherwise payable to me.