HIPAA NOTICE OF PRIVACY PRATICE
HIPAA NOTICE OF PRIVACY PRATICE

, have received or read a copy of this office's Notice of Privacy Practice.
Family / Friends that are allowed to obtained any of my personal information are:
*
*
*
*
For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Other (specify)
HIPAA VITAL INFORMATION ABOUT YOUR DENTAL INSURANCE
HIPAA VITAL INFORMATION ABOUT YOUR DENTAL INSURANCE

Our office is happy to help you file your insurance claim to receive the dental benefits that you and our employer are paying premiums for. Dental benefits plan can vary from company to company with different procedures cover's or not covered. Insurance companies base the amount that they will pay toward your dental treatment on restricted fee schedules related to premium payments and geographical location. In other words, your insurance plan will pay for only what it allows for each services, regardless of what the actual fee might be. Deductibles and co-payments are typically built in to most and their required payment is strictly regulated by state law. Both our office and you as the policy beneficiary can be prosecuted if deductibles and co-payments are not collected. Your Employee Benefits Director can usually help you become familiar with your plan and its restrictions, and our office will assist you in maximizing your benefits.

Our responsibilities are:

1. Complete your insurance claim forms and submit them to your carrier for you within 24 hours of treatment.
2. Use current American Dental Association coding for correct reporting of procedures.
3. Accept direct payment from your carrier and keep track of balances.
4. If necessary, re-file your insurance a second time within a 60 day period.

Your responsibilities are:

1. To pay fees not covered by your plan at the time of treatment.
2. To provide our office with necessary information concerning your insurance coverage to allow correct filing of claims.
3. To understand that your plan is a contract between you and your employer and the insurance carrier. Our office will do all we can to facilitate claims payment, but we do not have the power to make your plan pay.
4. To pay any account balance not paid by insurance after 2 billing attempts.

We thank you for choosing our office and will do all we can to help you obtain the benefits you deserve. Please sign this form below. We will keep one copy in your chart and will give you one copy for your own records.

I hereby authorized payment directly to the dental office of the insurance benefits otherwise payable to me. I understand that I am ultimately responsible for all costs of dental treatment. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers.

PATIENT INFORMATION
PATIENT INFORMATION

should be in xxx-xxx-xxxx format
should be in xxx-xxx-xxxx format


should be in xxx-xx-xxxx format
Medical History
Medical History

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 will receive. Thank you for answering the following questions.

To the best of my knowledge. the questions on this form have been accuretly answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsiblity to inform the dental office of any changes in medical status.