Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you (the patient). The Notice contains a Patient Rights section describing your rights under the
law (this may be requested at the front desk). You have the right to review our full Notice before signing Consent.
The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our
office. You have the right to request that we restrict protected health information about you that is used or
disclosed for treatment, payment or healthcare operations.
By signing this form, you consent to our use and disclosure of protected health information about your treatment,
payment and health care operations. You
have the right to revoke this Consent, in writing, signed by you.
However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent.
The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996
Dental is committed to providing all patients with exceptional service and quality care. Please review our
office guidelines and enter/submit your eSignature below. Thank you.
We respect the importance of your time and work hard to schedule appointments that accommodate the
scheduling needs of all of our patients. Broken and missed appointments create an inconvenience for other
patients as well as our practice. As a result, we follow the model commonly used by many other dental practices in
the area. If you find that you are unable to make your reserved appointment, we require a
48hour notice. You may leave a message at any time,
within 48 hours, by calling (850) 476-2602. There
will be a $25 fee assessed for every half hour missed without 48hour notification.
We understand that emergencies do occur and we do not wish to penalize patients for unavoidable situations; in
such situations we waive the first offense. We record all appointments, cancellation and no show appointments
and discourage repeat abuse of our scheduling guidelines.
Financial Obligation/Payment Guidelines
Patients with dental benefits: As a courtesy to our patients who have dental benefits, we are happy to file your
claims electronically from our office. Please understand that it is your responsibility to know your specific
plan/policy coverage. Your dental benefits may cover more or less than we estimate. Therefore, after we receive
payment from your insurance we will send you a statement with any remaining balance.
Patients without dental benefits: Patients without dental benefits are required to pay in full at the time services
Payment Plan Options
Sackheim Dental offers payment plan options
through Care Credit. Care Credit offers interest free payment options
along with extended payment plans. Log on to www.carecredit.com for more information. Brochures available
If you have any questions, please do not hesitate to ask. Thank
you for your cooperation and understanding as we
institute these policies. These policies will enable us to better serve the needs of all patients. I have read and understand the above policies.
I have read and understand the above policies.