HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, and/or other dental diagnostic means. I acknowledge that, because the practice of dentistry is not an exact science, no guarantees have been made to me. I agree that it is my responsibility to follow through with recommended treatment and/or follow-up evaluations. Failure to do so may result in pain, discomfort, loss of teeth, and/or other complications.

Allergic reactions can occur due to any medication, anesthetic or dental material used. In rare cases, injectable anesthetics may cause temporary or permanent nerve damage. The effects of x-rays may be harmful to an unborn fetus. Please inform us if there is any possibility that you may be pregnant. Patients with artificial joints or implanted devices are at risk of developing endocarditis. Endocarditis is an infection of the heart valves that can result from any dental procedure involving bleeding. In order to prevent endocarditis, it may be necessary to administer antibiotics prior to treatment. Patients with TMJ problems (jaw/ear clicking) must inform us of their condition prior to treatment to avoid further injury.

I have the right to refuse or accept any treatment proposed to me. Not objecting to treatment indicates that: I give permission for the treatment to be rendered; I understand the reasons for the treatment; I am aware of the risks involved in the treatment; I am aware of alternative treatments; I understand that no guarantees have been given to me; and, I will comply with home care instructions and recommended additional treatment.

I authorize the dental practice to release any information, including the diagnosis and records of treatment or examination for myself and my dependents, to third-party insurance carriers, payers, and/or healthcare practitioners. If I fill a prescription for a controlled substance, I understand that my identifying information may be entered into a statewide database of controlled substance prescriptions. The database is called the Prescription Drug Monitoring Program.

I authorize the payment from my insurance carrier to be submitted directly to the dentist or dental practice. I assume financial responsibility for any outstanding balance for services that are not fully covered by insurance. I understand that insurance estimates given to me are not guaranteed, and that final payment determination will be made by the insurance company upon processing of the claim. I agree to pay any deductible amount, co-insurance or any other balance not paid for by the insurance company. I understand that a late fee and/or a Finance Charge of 1.5% per month (18% APR) may be applied to past due accounts. I understand that all collection costs, attorneys’ fees, and court costs are my responsibility.

I understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand that Butterman Dental PC will comply with all applicable laws governing the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information. I understand that Butterman Dental PC will use commercially reasonable efforts to maintain the confidentiality of all patient information. You may request a copy of our Privacy Notice from us at any time.

I hereby certify that I have read and understand the above information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. It is my responsibility to provide accurate information regarding my medical history and to timely advise of any changes with respect to my medical history. If I did not understand any part of this document, I have asked for and received clarification. By signing this document, I am indicating that I have read and understood the above information.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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