Healthcare Dental Letter

DENTAL TREATMENT AUTHORIZATION LETTER

Date of Letter:   To:

Patient Information

Emergency Contact

Insurance Information

Medical & Dental History

Are you pregnant?   Are you currently under a physician's care?   If yes, physician name:

Proposed Treatment / Procedure

Affected tooth/area (if applicable):

Planned services (check all that apply):

Extraction    Root canal    Crown    Filling    Cleaning    X-ray

Other treatment:

Anesthesia, Risks, Benefits & Alternatives

I authorize administration of local anesthesia and other agents as deemed necessary by the treating clinician. I understand that use of sedation or general anesthesia carries additional risks including, but not limited to, respiratory depression, allergic reactions, cardiovascular events, aspiration, and in rare cases permanent injury or death.

The known risks of the proposed dental procedure(s) include infection, bleeding, swelling, postoperative pain, damage to adjacent teeth or restorations, nerve injury resulting in numbness or altered sensation, need for additional treatment, and failure of the procedure to produce the desired result. Benefits include restoration of oral function, relief of pain, and treatment of disease. Reasonable alternatives and their material risks and benefits have been explained.

I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

I acknowledge that risks, benefits, alternatives and expected outcomes have been explained to my satisfaction and I have had the opportunity to ask questions.

Authorization to Release Information & Billing

I authorize the dental practice and its agents to release medical and dental information necessary to insurance carriers, third-party payers, or other healthcare providers for purposes of treatment, claims processing, and quality review. This includes radiographs, clinical notes, and billing records as required.

I authorize release of records as described above.

I understand I am financially responsible for all charges not covered by insurance. I authorize payment of insurance benefits directly to the treating provider when applicable. I agree to promptly pay any remaining balance according to the practice's policies.

I accept financial responsibility and understand the billing arrangements described above.

HIPAA Notice & Patient Rights

I acknowledge that I have been presented with the practice's Notice of Privacy Practices outlining how my protected health information may be used and disclosed, and my rights regarding that information. I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.

I acknowledge receipt of the Privacy Practices Notice and my rights as described.

Right to Withdraw & Voluntary Consent

I understand that I may withdraw this consent at any time by submitting a written revocation, subject to the practice's record retention and legal obligations. My decision to withdraw consent will not affect actions already taken in reliance on this authorization prior to receipt of the revocation.

I understand my right to withdraw authorization and that withdrawal must be submitted in writing.

By signing below I certify that I have read and fully understand the information in this Dental Treatment Authorization Letter, that the procedures, risks, benefits and alternatives were explained to me, and that all of my questions have been answered to my satisfaction. If signing on behalf of the patient, I certify that I am the legal guardian or authorized representative and will attach supporting documentation if requested.

Patient initials:

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