Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or
Woman: Are you . . .
Are you alergic to any of the following?
Do you have, or have you had, any of the following?
To the best my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to
Signature of Patient, Parent or Guardian:
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
With my consent, Today's Dentistry, PC may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment, and Healthcare Operations (TPO). Please refer to Today's Dentistry. PC Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Today's Dentistry, PC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Today"s Dentistry, PC, Privacy Ofﬁcer at 12953 Publishers Drive. Suite 100, Fishers, IN, 46038. With my consent, Today's Dentistry. PC may call my home. cell phone or other designated locations, text my cell phone. email and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out (TPO) Treatment, Payment, and Healthcare Operations such as appointment reminders, insurance items, and any call pertaining to my clinical care. With my consent, Today's Dentistry, PC may mail to my home, e-mail or fax to a speciﬁed number or other designated locations any items that assist the practice in carrying out Treatment, Payment, and Healthcare such as appointments. reminder cards. pre-treatment information. dental claims and patient statements. Today's Dentistry will disclose to me any breach of unsecured protected health information. A separate authorization is required from me for Today's Dentistry to use or disclose any of my protected health information (PHI) for marketing purposes. By signing this form. I am consenting to Today's Dentistry, PC use and disclosure of my Protected Healthcare information to carry out Treatment, Payment, and Healthcare Operations. I also acknowledge availability to review and/or receiving a copy of Today's Dentistry, PC Notice of Privacy Practices. I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. lf l do not sign this consent, Today': Dentistry, PC may decline to provide treatment to me. Today's Dentistry, PC has my permission to discuss my Protected Health Information to carry out Treatment, Payment, and Health Operations with .Parent name of Spouse or other designated individual
Patient's Name Date
Signature of Patient or Legal Guardian
Printed Name of Legal Guardian or Patient Cell Phone
Written Financial Policy
Thank you for choosing Today's Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. This service is based on a friendly team and professional understanding between our office team and patient.
An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options
You can choose from:
We offer an 8% courtesy accounting adjustment to patients who pre-pay for their treatment in full with cash or check or 5% courtesy adjustment for pre-payment in full with credit card.3
Today's Dentistry requires payment prlor to the completion of your treatment. If you choose to discontinue care before treatment ls complete, your refund will be determined upon review of your case. For plans requiring multiple appointments. alternative payment arrangements may be provided. For larger. more comprehensive sedation treatment plans, a $310 deposit is required to secure each sedation treatment appointment. For patients with dental Insurance. we are contracted with three dental insurance carriers. Delta Dental _ Premiere. HRl_ Inc (Health Resources). and Aetna. We are happy to work with your carrier to maximize your beneﬁts and directly bill them for reimbursement for your treatment.2 Failure to pay in one of the above agreed upon manners (delinquent accounts) may be turned over to the collection agency. ln this case. the patient is responsible for all costs associated with the collection procedure: including attorney fees where applicable. Today's Dentistry charges $15.00 for returned checks. lf you have any questions. please do not hesitate to ask. We are here to help you get the dentistry you want or need.
1Subject to credit approval 2However. if we do not receive payment from your insurance carrier within 90 days. you will be responsible for payment of your treatment fees and collection of your beneﬁts directly from your insurance carrier. 3'Discounts do NOT apply to patient with an active Quality Dental Plan in affect.