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
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
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
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
Signature of Patient or Legal Guardian
Printed Name of Legal Guardian or Patient
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
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
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
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.