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By signing this form,
I authorize my insurance company to pay the dentist all Insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance
Asa condition of treatment by this office., financial arrangements must be made In advance. The practice depends upon reimbursement from patients for the costs Incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
Ali emergency dental services, or any dental services performed without previous financial arrangements, must be paid for In lull at the time services are performed unless other arrangements are made.
Patients with dental insurance understand thal all dental services are charged directly to the patient and that he or she iia personally responsible for payment of all dental services. This office will help prepare the patlenrs Insurance forms or assist In making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
I understand that any fee estimate for this dental care can only be eX1ended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing If credit is ex1ended. I further agree that the charges for services shall be as billed unless objected to, by me, In writing, within the time payment Is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
I understand that I may Inspect or copy the protected health information described by this authorization.
I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken In reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.
I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting Its confidentiality,
I allow this practice to disclose my Protective Health Information to the following Individuals: (This Information could Include: Name, Diagnosis, Test Results, Images and Account Information.)
By signing this form. I understand the above information and agree with its contents. and this will also serve as my electronic signature for the HIPAA Disclosure Fonn.
Section A: Patient Giving Consent
PURPOSE OF CONSENTS: By Signing this fonn, You will consent to our use and disclosure of your protected health infonnation to carry out treatment, payment activities and healthcare operations. NOTICE OF PRIVACY PRACTICE You have the right to read our notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health infonnatlon, and of other important matters about your protected health infonnatlon. A copy of our Notice accompanies this consent We encourage you to read it carefully and completely before signing this consent. We Reserve the right to change our privacy practice as described in our Notice Privacy Practices. If we change our Privacy practices we will issue a revised Notice of Privacy Practices, Which will contain the changes. Those changes may apply to any of your protected health infonnation that we maintain. You may maintain a copy of our privacy Practices, including any revisions of our Notices at any time by contacting:
Contact Person: Adel Shayegan Telephone: (623)388-5888 Address: 10750 W Mcdowell Rd Suite #B-200 City : Avondale State: AZ Zip: 85323
RIGHT TO REVOKE You will have the right to revoke this consent at any time by signing us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took In reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke consent.
I have had the full opportunity to read and consider the contents of this consent for and our notice of privacy practices. I understand that by signing this consent fonn , I am giving my consent to your use and disclosure of my protected health infonnation to carry our treatment, payment activities and health care operation.
By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature.
Your dental benefit program will assist you in obtaining and maintaining a supportive level of your oral health. Our office staff understands Dental Insurance and will be glad to assist you in obtaining the maximum benefits specified in your contract You must realize, however, that;
Our office will be glad to discuss your proposed dental treatment and answer any questions you may have about the involvement of your dental benefit program in receiving dental care.
Dr. Adel Shayegan is a license Arizona General Dentist Who does implants, 3rd Molar extractions and orthodontic work and periodontal surgery. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made, you will be made responsible for legal fees, collection agency fees, interest charges and any other expense incurred in collecting your account. I authorize the staff to perform any necessary services needed during the diagnosis and treatment I also authorize the provider to release any information required to process insurance claims. I understand the above information, guarantee this form was completed correctly to the best of my knowledge, and understand it is my responsibility to Inform this office of any changes to the information I have provided.
Dr. Adel Shayegan es un dentlsta general con licencia en el estado de Arizona, quien hace implantes , extracciones de muelas de juicio, frenos, y cirugia periodontal. Se requiere pago el mismo dia del servicio, al menos que ya hayan hecho arreglos de pago. Si la cuenta se atrasa usted sera responsable por las cuentas legales, cargos de interes, todos los cobros de la agencla de colecci6n y cualquier otro cobro en acuerdo con su cuenta. Yo autorizo que el doctor y sus empleados me diagnostiquen y que me hagan el tratamiento necesario. Yo autorizo que den mi infonnacion a mi seguro dental para que se paguen los cobros necesarlos. Yo entiendo que toda la lnformaci6n que he presentado y garantizo es correcta y lo he completado lo mejor que pude. Entiendo que es mi responsabilldad informarle a la oficina de cualquier cambio sobre ml lnformaci6n.
By signing this form, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. I am aware that I must notify the practice of any future changes. This will also serve as my electronic signature.
