Authorization: The information above is true and correct to the best of my belief. I authorize any provider of services to furnish any information requested. I also hereby authorize my dental administrator to release insurance information that may be necessary to determine benefits payable under my group benefits plan. A Photostat copy of this authorization shall be considered as effective and valid as the original. I understand I am responsible for all charges of all services rendered to me or any member of my family. I also understand that an assessment of $75.00 an hour will be charged to my account without at least 2 business days’ notice to cancel an appointment. Although I have requested the dentist to bill my insurance company on my behalf, I clearly understand that is still my responsibility to make sure that my account is paid within 45 days. If for any reason my insurance doesn’t pay any portion of my bill, I further agree to make prompt payment of the outstanding balance. I hereby authorize payment directly to the provider of the dental benefits otherwise payable to me.

Do you have, or have had, any of the following?

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

On a scale of 1 to 10, with 10 being the highest rating:

Please rank the following in the order in which they would keep you from having necessary or elective dental treatment?

It is necessary to develop a rapport with our patients. Many new patients have had a past unpleasant dental experience. It is crucial to us to know and understand your concerns. We are committed to taking the time to get to know you, discuss your concerns, your fears, and your dental expectations.

Please place a check mark in the box next to the statement that concerns you or describes your problem.

Partnership Pact:

I ask that you honestly inform me of all my dental problems. I want you to make me aware of the best quality dentistry available today. Then we can discuss how I can make healthy choices that will work within my budget. I also want to know all the pain relief options available to me, how each dental procedure will work, and how much of my time will be required.

Our office wants all our patients to be able to comfortably afford dental care. We proudly offer the following financial policy so that our patients can have the opportunity to decide which payment option best suits your needs.

Insurance

We will attempt to verify your benefit plan and give you as close of an estimate as we can for your treatment. Please understand that we don't know exactly how much your dental benefits will pay until the claim comes back. We do our best to give you an accurate estimate.

We will try to answer any questions we can about your dental benefit plan and, when possible we will assist in resolving any issues with claims. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your dental benefit company has not paid for your treatment, you will be responsible to pay your account.

Payment Options

Cash or Check: We are happy to offer a 5% pre-payment courtesy for all treatment paid in full in advance of treatment.

Credit Card: Our office accepts VISA, MasterCard, Discover, American Express and Care Credit.

Appointments

Appointments times are reserved just for you. If you are unable to keep your appointment, please notify our office at least 2 business days in advance so that we may schedule a new time for you and fill the open time from your appointment.

Please note that there will be a charge of $75 for any appointment missed without a 2 business days' notice.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) I have certain rights to privacy regarding my protected health information. I understand further that this information can and will be used to:

1. Conduct, Plan and Direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your 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 from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice Of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

We take photos of your teeth, gums and smile as well as x-rays as part of our records. We sometimes take intra-oral photos for documentation as well, for insurance claims.

I acknowledge and authorize KORsmiles Dental to take photographs, video and x-rays of my face, jaw, teeth and smile as a record of my care.

Occasionally we use patient case photos for social media and in our website gallery. Please select from multiple choice question if you agree to have your full face before and afters shown, or just images of your teeth/smile before and afters shown.

By signing this, you agree that your picture(s) can be shown publicly and you do not expect compensation, financial or otherwise for the use of these photographs.