Healthcare Dentist Agreement

HEALTHCARE DENTIST AGREEMENT

Parties and Effective Date

Dentist Name:     Patient Name:

Effective Date:

Patient Information

Insurance Information

Medical History

Description of Dentistry Services and Consent

Services to be provided:

I authorize the Dentist and staff to perform the dental procedures described above and such additional procedures as are necessary and advisable in the professional judgment of the Dentist. I acknowledge that no guarantee has been made regarding results.

Risks and potential complications include, but are not limited to: infection, bleeding, bruising, temporary or permanent nerve injury, sinus involvement, allergic reaction, failure of treatment, and need for additional treatment. I have the right to ask questions and to refuse any recommended procedure prior to its performance.

Financial Responsibility and Assignment of Benefits

Patient Responsibility: The patient is responsible for payment of all charges for services rendered. Estimates are provided as a courtesy and are not a guarantee of the final charge. The patient agrees to pay co-payments, deductibles, and any amounts not covered by insurance.

Assignment of Benefits: I authorize payment of dental benefits directly to the Dentist to the extent permitted by my insurer. I understand that I remain responsible for any balance not paid by my insurer.

Cancellation, No-Show, and Collections

The patient agrees to provide timely notice for cancellations. Missed appointments or cancellations without sufficient notice may incur a fee. Accounts delinquent beyond the stated period may be referred to collections; the patient shall be responsible for collection and legal costs.

Authorization to Release Records and HIPAA Acknowledgment

I authorize release of my dental and medical records, including radiographs and clinical notes, to my insurance carrier, referring provider, or other health care providers as necessary for treatment, payment, or health care operations. I understand that information disclosed may include sensitive health information.

I acknowledge receipt of the practice's Notice of Privacy Practices, which explains how my protected health information may be used and disclosed and how I can obtain access to this information.
Acknowledgment: I acknowledge that I have been provided the Notice of Privacy Practices.

Consent for Anesthesia / Sedation (if applicable)

If sedation or anesthesia is recommended, the practitioner will explain the intended agent, potential risks, and alternative options. I consent to the administration of anesthesia or sedation deemed appropriate by the Dentist and qualified personnel, and I understand pre- and post-operative instructions must be followed.

Pre-procedure instructions provided and understood: Yes

Limitations, Governing Law, and Entire Agreement

This Agreement contains the entire understanding between the parties with respect to the subject matter herein. Any disputes arising under or relating to this Agreement shall be governed by the laws of the state where the dental practice is located. If any provision is held invalid, the remaining provisions shall remain in full force and effect.

Patient Representations and Certifications

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have disclosed all medical conditions, medications, and allergies. I understand that failure to disclose material information may increase the risk of harm.

Additional Authorizations

Revocation

The patient may revoke authorizations given herein by providing written notice to the dental practice, except to the extent that action has already been taken in reliance on this Agreement.

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