New Patient Consent to Treatment and
Payment Form

Home / New Patient Consent to Treatment and Payment Form

New Patient Consent to Treatment and Payment Form

CONSENT FOR TREATMENT AND PAYMENT AGREEMENT

I hereby authorize Midtown 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 DISCLSURE OF PROTECTED HEALTH INFORMATION

I consent to the use and disclosure of my Protected Health Information by Midtown Dental for the purposes of treatment, payment and health care options.For example: my treatment practitioner may furnish Protected Health Information maintained by Midtown 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 Midtown Dental offers the option of accepting payment directly from insurance, however ultimately my account is my responsibility

FINANICAL AGREEMENT

In consideration for services rendered by Midtown Dental, I guarantee prompt payment for services at the time they are provided. I am aware that because Midtown 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 Midtown 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.

I have read all of the above statements and accept the terms and conditions as stated.