By agreeing with this consent form, you agree to abide by the following Financial Policy below and accept the receipt of our Privacy Policies. 

-You certify that if you, and/or your dependent(s), have insurance coverage as submitted on the following registration form and you assign directly to your dental practitioner all insurance benefits, if any, otherwise payable to you for services rendered.

-You authorize the use of your signature on all insurance submissions.

-Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services.

-Financial Policy-

At Stress-Free Dentistry full payment for all services are due at the time of checking-in for any appointment when services are expected to be rendered. 

When using a third party payer, such as an insurance company, you are responsible for the entire amount charged whether or not paid by insurance. 

The office will only collect your estimated co pay the day of service and the remaining balance will be sent to the insurance company for payment of the remainder.   

If our office is contracted with your insurance company you will never be charged more that what is allowed on their final EOB (Explanation of Benefits) form sent to you.  

If you have more than one insurance policy our office will file only to the primary insurance carrier, and you will need to submit and follow up with the secondary.  

Since our computer systems are not part of your insurance company all quotes will always approximate and estimate the insurance coverage but are not direct quotes from your insurance company.  We strive for 100% satisfaction and accuracy.  All estimates are based on the accuracy of the information given to Stress-free Dentistry by you, the patient, received by the insurance company sometimes by an agent on the phone, and how the staff enters that information.  Most of the time our estimates are either fully accurate or may have small differences of less than $50 from what is the final amount paid by the insurance, but sometimes with large procedures the differences in what is approved and what is estimated can be significant.  If you are concerned with preventing possible differences in estimated and adjudicated payments then please request that the office submit Pre-Treatment estimates for you.  Please be aware that submitting Pre-Treatment estimates to your insurance and following up on them will delay your treatment, therefore we do not submit them as a default.  You will need to ask, and the staff will be happy to submit one whenever you would like.           

Notice of Privacy Practices

This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully.

Our Legal Duties

We are required by law to maintain the privacy of your protected health information (PHI), provide you with this notice of our legal duties and privacy practices, and notify you in the event of a breach of unsecured PHI. We must follow the privacy practices described in this notice while it is in effect. We reserve the right to change our privacy practices and the terms of this notice at any time, as permitted by law. Any changes will apply to all PHI we maintain. We will post the new notice in our office and provide copies upon request. 

How We May Use and Disclose Your Health Information

We may use and disclose your health information for the following purposes:

• Treatment: To provide, coordinate, or manage your dental care and related services. For example, sharing information with specialists or laboratories involved in your care.  Payment: To obtain payment for services, confirm coverage, and carry out billing and collection activities.  Health Care Operations: For business activities such as quality assessment, training, licensing, audits, and administrative functions.  Appointment Reminders: We may contact you by phone, email, mail, or other means to remind you of appointments or provide information about treatment alternatives or other health-related benefits. Legal Requirements: We may disclose your health information when required by law, including reporting suspected abuse or neglect, or for national security purposes. Family and Others Involved in Care: With your consent, we may share information with family members or others involved in your care or payment for services.

Your Rights

You have the right to:

• Request restrictions on certain uses and disclosures of your health information.  Receive confidential communications.  Inspect and obtain a copy of your health records.  Request amendments to your health records.  Receive an accounting of disclosures of your health information. Obtain a paper-copy of this notice upon request.

*Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent.