If the same as the patient, write self

We need the above information so that we can help you obtain the dental insurance benefits you are eligible for. We can NEVER guarantee payment by your insurance company. The insurance company’s contract is with you and your employer.

WHOM MAY WE THANK FOR REFERRING YOU?

AGREEMENT TO PAY

I understand that I am responsible for payment of services rendered and also am responsible for paying any co-payment and deductibles not covered by my insurance. I hereby authorize payment directly to Dental Zone. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including diagnosis and records of treatment or examination rendered, to my insurance company.

RESCHEDULE / CANCELLATION APPOINTMENT

If you are unable to keep your scheduled appointment, kindly give us 48 hrs. notice. Otherwise we reserve the right to charge $50.00 for time reserved.

07. Do you have or have you had any of the following diseases or problems? Please check Yes or No

Women

08. Are you allergic to any of the following

03. Does any of the following apply? ( Please check Yes or No )

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY - THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US

Your protected health information (i.e., individually identifiable information, such as names, dates, phones/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

* To other health care providers (i.e., your general dentist, oral surgeon, etc) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);

* To third party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.)

* Internally, to all staff members who have any role in your treatment;

* To your family and close friends involved in your treatment; and/or, any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

* Request restrictions on the use and disclosure of your protected health information;

* Request confidential communication of your protected health information;

* Inspect and obtain copies of your protected health information through us;

* Amend or modify your protected health information in certain circumstances;

* Receive an accounting of certain disclosures made by us of your protected health information; and,

* You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filled with in 180 days of the violation)

We have the following duties under the privacy rules:

* By law, to maintain the privacy of protected health information and to provide you with this notice setting fourth our legal duties and privacy practices with respect to such information;

* To abide by the terms of our Privacy Notice that is currently in affect;

* To advise you of our right to change the terms of this Privacy notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy notice

Please note that we are not obligated to:

* Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following: