HIPPA Patient Consent Form - 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 (HIPAA).
The patient understands that:
- Protected health information may be disclosed or used for treatment, payment or health care operations.
- The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
- The patient has the right to restrict the use of their information.
- The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
- The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore payment in full is required at the time services are rendered.
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 are rendered.
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 upon request.
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.