Keith W. Kelley, DDS • 1913 W. South Blvd. • Troy, Michigan 48098 • (248) 828-3185
GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Keith W. Kelley, DDS to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient's dental condition and needs. I authorize Keith W. Kelley, DDS to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Keith W. Kelley, DDS choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Keith W. Kelley, DDS. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status. FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. This ofEce will not bill anon-custodial parent. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I further consent to and agree to pay a 7% annual finance charge that will be applied to any balance over 30 days; returned checks will incur a $25.00 fee. I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Keith W. Kelley, DDS and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.
Notice of Privacy Practices (below) Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information ("PM") and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging receiving notice of our practices' policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable) and my other medical providers.
Keith W. Kelley D.D.S.