PATIENT CONSENT FORM

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have a certain right to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up amongst the multiple healthcare providers who may be involved in that treatment directly or indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operation such as, quality assessments and physician certifications.

I have been informed by Dr. Jay Dorgan of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact Dr. Jay Dorgan at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

Payment for services is due at the time services are rendered, unless payment arrangements have been approved in advance.
If you have dental insurance we will work hard to help you receive your maximum allowable benefit. In order to achieve this goal we need you to take the necessary steps to understanding your insurance plan. There being so many different providers and plans, it is impossible for us to know all of our patient’s benefits. It is very important for you as a dental insurance policy holder, to be aware of the plan benefits, deductibles, and exclusions. Plan benefits can be obtained by calling your dental insurance company. We will gladly discuss your proposed treatment and answer any questions that you may have relating to your insurance. You however, must be aware that:

1. Your insurance is a contract between you, your employer and the insurance company. We are not a part of that contract.
2. Most insurance companies have a yearly deductible that is your responsibility to pay.
3. Most insurance companies only pay a percentage of the cost (such as 50% or 80%) and you will be responsible for the remainder.
4. Not all services are a covered benefit in all contracts. It is important for you to contact your insurance provider and ask if there are any clauses or waiting periods.
5. As a courtesy to you, our office will submit claims to your insurance provider; if for any reason the claims go unpaid you will be responsible for all charges.

If you have any questions regarding this information, or any uncertainty regarding insurance coverage please don’t hesitate to ask us, we are here to help you in any way we can.

In order to serve the needs of all of our patients, we make every effort to be respectful of your schedule. If you cannot keep an appointment, we request that you give us a minimum of 24 hour notice. Patients who fail to arrive for their reserved appointments or who cancel without 24hr in advance will be charged a missed appointment fee of $65.00. Please note that this missed appointment fee is NOT covered by any insurance plan and is your responsibility to pay. We understand that situations may arise that may make it impossible to give 24hr notice, and each incident will be given individual consideration based on your appointment history.