In order to evaluate your needs and expectations as accurately as possible, please help us by answering the following question, circle any words that may apply, and provide us with any additional information.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Vital Dental to use and disclose my protected health information to carry out:
I have also been informed of , and given the right to review and secure a copy of the Vital Dental Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry our treatment, payment, and health care operations, but that Vital Dental is not required to agree to these requested restrictions. However, if Vital Dental does agree, Vital Dental is then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that occurred prior to the date I revoke this consent is not affected. Unless you object, Vital Dental may disclose to a member of your family, a relative or any other person you identify, your personal health information that directly relates to that person's involvement in your health care.
We value your time so you can expect us to see you at the appointment time and to keep your time spent in our waiting area as sort as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Please make every effort not to change your scheduled appointment. In the event you must change your appointment, please provide us at least 2 business days of advanced notice so that we may use your time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. We value your time, please value ours. A fee of 50$ may be charged for appointments broken, changed or rescheduled with less than 36 hours notice.
Unless another financial option is pre-arranged, payment in full is due the day of treatment. Should a patient have dental insurance with assigned to Vital Dental, the estimated patient portion with be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full.
Dental Insurance plans often pay less than actual fee for service, therefore the patient or guarantor is the responsible party for all dental services provide. Dental insurance, in most cases, is a benefit with limitations and should not be explained to you during your initial appointment or during a separate treatment discussion/consultation appointment. I also authorize to keep my signature on file with Vital Dental in order to process dental insurance claims on my behalf.
Patients are responsible to set up assignment of benefits with their insurance.
I understand and will comply with the Vital Dental Appointment Policy.
I understand and will comply with the Vital Dental Financial Policy
I understand and agree to the General Consent To Treatment.
I authorize the Release Of Information.