All-In-One Form

SIGNATURE ACKNOWLEDGEMENT

My signature below indicates: 1) That, to the best of my knowledge and ability, I have provided the most accurate information related to the above-named patient and that the dentist will rely on this information for treatment decisions. 2) That I release Mobile Dental Associates and the treating dental provider(s) from any responsibility that may arise related to inaccuracies or omissions of the patient's health history, medical/dental conditions, allergies, medications etc. 3) I also hereby release Medical and or Dental records for the above-named patient upon the request of Mobile Dental Associates.

DOCTOR(S) Currently caring for the patient

THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. If you sign a Consent Form, we may use and disclose your medical records only for each of the following purposes: treatment, payment, and healthcare operations. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. For example, teeth cleaning. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, sending your bill for your visit to your insurance company for payment. Healthcare Operations: include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may, without prior consent, use or disclose protected health information to carry out treatment, payment, or healthcare operations in the following circumstances:

• In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment
• If we are required by law to treat you, and we attempt to obtain such consent but are unable to contain such consent; or
• If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with a member of our staff. Your signature below is an acknowledgement that you have reviewed our Notice of Privacy Practices and can access it or electronically and or print a copy of it at any time on our website at: www.mobiledentalassociates.com. Your signature also consents to the use and disclosure of your personal health information by your dental office for treatment, appointments, billing/payment, and healthcare operations as outlined in this Notice of Privacy Practices.

Payment for all services provided by Mobile Dental Associates caregivers is expected at the time of service unless other arrangements have been mutually agreed to beforehand. We accept checks, debit cards, major credit cards(Visa, Mastercard, American Express, Discover), ACH payments, Bank Wires/Transfers, Care Credit, and payments through the Zelle banking app. There will be a 3.75% convenience fee for paying with a credit card or debit card. Any other payment arrangements must be mutually agreeable to all parties prior to the day of treatment and will be secured with a payment method like ACH or Credit Card. If a patient’s health situation declines such that it prevents the completion of a multi-visit procedure (Ex: Crown, Bridge, Denture) the amount due will be reasonably prorated for the portion of services that were completed and the expenses incurred to date. If there is a remaining unpaid prorated amount, that amount will be due by the patient or patient’s representative. Alternatively, if there is a credit on the account in excess of the prorated charges, a partial refund will be issued.

MISSED/CANCELLATION/NO-SHOW POLICY (24 HOUR NOTICE REQUIRED)

 

When our office schedules an appointment, we set aside and dedicate our chair time, materials, team labor and travel time just for the patient. We simply ask that if the patient must reschedule the appointment, that we are provided at least 24 hours’ notice. This courtesy makes it possible for us to offer the reserved time to another patient. There is a minimum charge of $75.00 and $75.00 per additional hour for failing or canceling appointments with less than 24hrs notice. Repeated cancellations or missed appointments will result in loss of future appointment privileges. We appreciate your cooperation and understanding.

Our practice does not typically accept insurance as a form of payment and payment is due from the patient at the time of service unless other arrangements have been made. However, we are happy to file an insurance claim as a courtesy on the patient’s behalf. The insurance company, depending on the patient’s in & out-of-network benefits, may partially reimburse the patient for the services that they choose to cover. Mobile Dental Associate doctors are OUT-OF-NETWORK providers with most insurance companies with a few exceptions, but most PPO policies may provide partial payment for some services. Please remember that we are typically not directly contracted with the patient’s insurance company and that contract is between the patient and the insurance company. If the patient has an HMO policy, we can still provide services but most often there will not be any reimbursement expected from the carrier as HMOs typically require the patient to see only a preselected in-network HMO provider. In some cases, Medicaid will provide limited benefits that are preauthorized and approved. We can help with that process. Medicare does not cover dental services. See https://www.medicare.gov/coverage/dental-services. Exception: There are some Medicare Advantage Plans that offer Limited Dental Benefits for which we will help the patient receive any benefits the insurance approves.

Unencrypted email and texts are not a secure form of communication. There is some risk that any individually identifiable health information and or other sensitive or confidential information may be misdirected, disclosed to, or intercepted by unauthorized third parties. Your signature below consents to the use of email and SMS text communications regarding your dental care. Examples of such communications are, but not limited to appointment reminders, appointment confirmations, patient satisfaction surveys, financial transactions (receipts for payment, statements, account history reports, etc.), periodic announcements, discounts, specials, seasonal promotions etc. Your consent To Electronic Communications can be modified or retracted at any time by notifying us in writing or by email to: contact@mobiledentalassociates.com.

I authorize and consent to the use of photographs & or x-rays of me by Mobile Dental Associates (MDA). I grant MDA permission to reproduce, print and or publish these images in professional publications or in the form of prints, film or slides in connection with articles and lectures related to dentistry so long as my name and my likeness are not revealed. I acknowledge that my participation is voluntary and that I will not receive any compensation, financial or otherwise, with respect to the taking, use or publication of these photographs and agree that publication of photographs confers no rights of ownership or royalties whatsoever.

Consent to X-Rays & Photography for Marketing Purposes

 

I also consent to the use of my photographs or images for marketing materials including website and patient education for Mobile Dental Associates only. I further understand that if the photographs and/or images are used, my name or similar identifying information will not be used and that any full face or comparable photos will be altered to conceal my identity with the use of sunglasses or black bar blocking the areas of my eyes. I specifically waive any claim for invasion of my personal privacy in connection with such photographs/x-rays. I acknowledge that my participation is voluntary and that I will not receive any compensation, financial or otherwise, with respect to the taking, use or publication of these photographs and agree that publication of photographs confers no rights of ownership or royalties whatsoever.

1) EXAMINATIONS AND X-RAYS I understand that the initial visit will likely require radiographs(X-Rays), intra-oral photographs, and in some cases digital scans in order to complete the examination, diagnosis and treatment plan. I understand & consent to the diagnostic treatment to be performed as deemed appropriate by the Dentist.

2) DENTAL PROPHYLAXIS (CLEANING) I understand that this treatment is preventative in nature, is intended for patients with healthy gums, and is limited to the removal of plaque and calculus from the tooth structures in the absence of periodontal (gum) disease.

3) TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD) I understand that popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with dental treatment are usually transitory in nature and well tolerated by most patients, I understand that should the need for treatment arise, then I will be referred to a specialist for treatment, the cost of which is my responsibility.

4) DRUGS, MEDICATION AND SEDATION I have been informed and understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). I have informed the Dentist of any known allergies. They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic, medication and drugs that may have been given me in the office for my care. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection and pain and potential resistance to effective treatment of my condition. I understand that antibiotics can reduce the effectiveness or oral contraceptives (birth control pills). I understand that all medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking.

CONSENT & ACKNOWLEDGEMENT: I understand that dentistry is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment I have requested and authorized. I understand that each Dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist or corporate entity, other than the treating Dentist, is responsible for my dental treatment.