Consent For Treatment And Payment Agreement
I hereby authorize 9th Avenue Dental to perform any care and treatment such as an examination, laboratory test and or procedures, administer local anesthetics, medication and treatment, as may be directed by my dentist or treating practitioner. I acknowledge that no guarantees have been made to me as to the effort of such examinations, tests, procedures or treatment of my condition.
Consent To Use And Disclosure Of Protected Health Information
I consent to the use and disclosure of my Protected Health Information by 9th Avenue Dental for the purposes of treatment, payment and health care options. For example: my treatment practitioner may furnish Protected Health Information maintained by 9th Avenue Dental and they might release medical information to any third party, including my employer, which may be responsible for payment of my dental expenses. (Release of medical information to employers is limited to those employers who are directly liable for the cost of the patient’s dental care benefits through the employer, self insured group health plan, or in other circumstances in which disclosure is legally allowed).
Insurance Authorization
I understand that I am responsible for knowing the terms and conditions of my insurance coverage. I further understand that I may be responsible for obtaining prior authorization for certain procedures in order for my insurance company to pay for those services. I understand that I am personally responsible for payment and it is my responsibility to insure that reimbursement is received from my insurance company. As a courtesy 9th Avenue Dental offers the option of accepting payment directly from insurance, however ultimately my account is my responsibility
Financial Agreement
In consideration for services rendered by 9th Avenue Dental, I guarantee prompt payment for services at the time they are provided. I am aware that because 9th Avenue Dental offers direct billing to my insurance company, I will be asked to pay my portion of 20% up front on the date of service or the exact portion, should it be known on the date of service. If 9th Avenue Dental does not receive payment within 30 (thirty) days from the date such balance is due, the bill may be turned over to an attorney or a collections agency and if so, I agree to pay all reasonable costs including attorney’s fees and/or collection fees in addition.
Consent For Release Of Patient Information
We are committed to protecting the privacy of our patients’ personal information and to utilizing personal information in a professional and responsible manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstance in this form, we also collect, use and disclose personal information when permitted or required by the law.
We collect information from our patients such as names, home address, work addresses, home/cellular telephone numbers, work telephone numbers and email addresses. (Collectively referred to as – Contact Information”) Contact information is collected and used for the following purposes:
- To open and update patient files.
- Invoice patients for dental services, to process credit card payments, or collect unpaid accounts.
- To process claims for payment or reimbursement from third party health parties or insurance companies.
- To send reminders to patients concerning the need for further examination or treatment.
- To send patients informational material about our office, dental materials or services offered.
- To follow up with treatment and/or customer service.
How We Collect And Disclose Your Patient Information
Contact information is disclosed to insurance companies, third party health benefit providers where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment and has authorized us to submit a claim on their behalf. Financial information may be collected to make arrangements for the payment of dental services.
We collect information from our patients about their health history, their family health history, physical condition and dental treatments. (Collectively referred as “Medical Information”). Patients’ medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients’ medical information is disclosed for the following purposes:
- To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment, or the patient has asked us to submit a claim on their behalf.
- To other dentists and dental specialists, where seeking a second opinion and the patient has consented to seeking a second opinion.
- To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
- To the other dentists and dental specialists where those dentists have asked us, with the consent of the patient to provide a second opinion.
- To the other health care professionals such as physicians if the patient, with their consent, has been referred to us by the other health care professional for either a second opinion or treatment.
- Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of regulatory activities in public interest.
