PERSONAL REPRESENTATIVE, FAMILY OR OTHER ENTITIES WHO ARE AUTHORIZED ACCESS TO PROTECTED INFORMATION TO BE USED
AND/OR DISCLOSE (OPTIONAL)
Name of person and/or entities you are authorizing
to make use of and/or to disclose your protected health information regarding
treatment, payment and other healthcare operations.
AUTHORIZATION FOR USE OF ANSWERING MACHINE AND/OR VOICE MAIL
Burk & Flinn Orthodontics, PA doctors and staff are sometimes unable to contact patients directly
during normal business hours. On these occasions our offices leave messages on
communication devices provided by our patients. Due to the new federally
mandated HIPAA Privacy Rule we must obtain your authorization to continue this
mode of communication. Protected Healthcare Information that we may possibly
disclose on your home, work or cell phone would include but is not limited to: prescription/pharmacy information, appointment instructions
for visits and procedure, and scheduling information.
Signature:
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I authorize my insurance carrier to release information regarding my insurance
coverage to Burk & Flinn Orthodontics, PA. I also authorize agents of any
hospital, treatment facility or previous physicians and or dentists to furnish
Burk & Flinn Orthodontics, PA copies of any and all records of my medical and/or
dental history. I authorize the release of my medical and/or dental records to
any federal, state or accreditation agency. I agree to a review of my records
for purpose of internal audits, research and quality assurance reviews within
the office.
My right to payment for all procedures, supplies and services including major
medical benefits are hereby assigned to Burk & Flinn Orthodontics, PA. This
assignment covers any and all benefits under Medicare, all government sponsored
programs, private insurance companies and other health plans. I acknowledge this
document as a legally binding assignment to collect my benefits as payment for
service. In the event my insurance carrier does not accept assignment of
benefits, or if payments are made directly to my representative, or me, I will
endorse such payment to Burk & Flinn Orthodontics, PA.
I understand that when paying by check to Burk & Flinn Orthodontics, PA, I will
be responsible for a $30.00 fee if a check is returned. This does not include
any other fees applied by your bank.
DIVORCED PARENTS of PATIENTS: By signing below, the
adult who signs a minor child into our practice on the day of service accepts
responsibility for payment. This office does not promise to send bills or
records to the other parent/guardian for issues of payment communication. We
will communicate about treatment and payment with the parent who is listed on
the contract as the responsible party. Parents are responsible between
themselves to communicate with each other about treatment and payment issues.
I understand that missed appointments and appointments cancelled without 24
hours notice are subject to a $25 fee.
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