Please rate the following accordingly:
Consent: I, the undersigned, hereby authorize Eagle MTN Dental, LLC and its doctors and/or employees to take X-rays, study models, photographs and/or any other diagnostic aids deemed appropriate by a doctor to make a thorough diagnosis of my dental needs. I also authorize any and all forms of treatment, medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I have read, understand, and agree to the above terms and conditions.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACYPRACTICES and AUTHORIZATION TO RELEASE
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge I have received a copy of Eagle MTN Dental, LLC HIPAA Notice of Privacy Practices:NOTE: YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT.
I, the undersigned, have received a copy of Eagle MTN Dental, LLC Notice of Privacy Practices.
Authorization to Release Information (Optional)
I, the undersigned, authorize the following person(s)to have access to the information covered under the Privacy Practice regarding myself.
FINANCIAL POLICY and AGREEMENT
Thank you for choosing Eagle MTN Dental, LLC as your dental healthcare provider. We are committed to providing you with the highest quality dental care.
The following is a statement of our financial policy which we require you to read, agree to and sign prior to any treatment. We thank you for the opportunity to serve you and welcome any questions you may have concerning our financial policies.
Dental Insurance Overview
As a courtesy, we will assist with the processing of all insurance claims. We will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. We will strive to provide an accurate estimate; however, your insurance company and your plan benefits are ultimately determined by the carrier.
All charges incurred are your responsibility, regardless of insurance coverage. As your dental care provider, our relationship is with you—our patient—not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.
Our practice is committed to providing the best treatment for all patients and we will charge what is usual and customary for the local market. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary fees.
Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 45 days, we will ask that you contact your insurance company to obtain an expected payment date. If payment is not received within 60 days of the filing date, and/or your claim is denied, you will be responsible for paying the amount in full immediately. Any amount not paid will be subject to 18% interest per annum. We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.
To pursue treatment, your signature is required on this form as well as any other forms required by your insurance company.
I have read, understand, and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided by this office for myself or my dependents is my own, and/or attorney fees will be added to any overdue balance that requires collection initiatives.
I understand that in the absence of prompt payment, my personal and financial records concerning these professional services will be released to Eagle MTN Dental, LLC’s legal representative(s) for collection. The legal representative will act as the provider's “business associate” in compliance with the federal Health Insurance Portability and Accountability Act.
By signing below, I am authorizing Eagle MTN Dental, LLC to call me at any number provided. I also agree to any fees or charges that you may incur or for incoming or outgoing calls, to or from any such number, without reimbursement.
Eagle MTN Dental, LLCCONSENT TO PROCEED
I authorize Eagle MTN Dental, LLC and its associates or assistants to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have a responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.
I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval.Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation.
I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions.
After lengthy appointments, jaw muscles may also be sore or tender. Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek, or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required.
I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal.
I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva, or Actonel, may result in complications of non-healing of the jawbones following oral surgery or tooth extractions.
I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with standard dental preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.