Please indicate if you have experienced any of the following
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
- Obtaining payment from third party payers (e.g., my insurance company);
I have also been informed of, and given the right to review and secure a copy of your Notices 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 herby authorize Rivers Bend Family Dental to disclose my personal health information to the following individuals.
By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.
If the account(s) that I am the responsible party for should ever fall into a delinquent collection status, I understand I am responsible for my delinquent balance and the additional collection agency fee of 30%.