1. I am consenting to examination and treatment by Dentist
2. I understand that if I have dental insurance, they may not cover all of the provided services and I may ultimately be responsible for paying for all or part of this/these service(s). I authorize the payment of submitted insurance claims and/or third party claims be paid directly to the Dentist
3. I authorize North Central Family Dentistry to release my dental records and any other information relating to my care to any person, office or company who may need them for treatment, payment or other health/dental care as outlined in the office's Notice of Privacy Practices.
4. Acknowledgment Receipt of Notice of Privacy Practices: I understand that North Central Family Dentistry may share patient health/dental information for treatment, billing and health/dental operations under the federally mandated Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). All reasonable efforts will be made to protect the privacy of patient health/dental information, whether it is maintained on paper or electronically, and regardless of how it is communicated.
I have received a copy of the Privacy Notice for North Central Family Dentistry