We make every effort to keep down the cost of your oral surgical care. You can help, by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees and court costs.

This signature on file is my authorization for release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me. I certify that I have read and I understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.

I certify that I have read and I understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.

This Notice of Privacy Practices includes the following:

• A statement that this practice is required by law to maintain the privacy of protected health information.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
• A description of uses and disclosures that are prohibited or materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
• My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
  • The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
  • The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
  • The right to receive confidential communications of protected health information.
  • The right to inspect and copy protected health information.
  • The right to amend protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.