I understand that I have certain rights of privacy regarding my protected health information.. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
• Obtaining payment from third-party payers (e.g. my insurance company)
• The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. 

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing at any time. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

Signed this

day of

20

Print Patient Name

Relationship to patient

Parties to whom Infomation May Be Disclosed:

Orthodontics is covered at the discretion of your insurance company; some types of treatment might be excluded under your coverage. Usually, benefits start when initial appliances are placed and are paid during the course of the estimated treatment time, not in a single payment. Prior to treatment, a payment arrangement will be made with you which takes into account the amount expected to be received from your insurance company. If your coverage should change or be terminated, any balance in your insurance account would then become your responsibility. Should your employment end, benefits may end on your last workday.

The following could affect your coverage:

• Extractions for orthodontics are sometimes considered as part of your maximum orthodontic benefit.
• You must notify this office immediately if your insurance coverage changes so that appropriate paperwork can be filed and your benefits can continue without interruption.

We are here to help you. Please do not hesitate to call at any time with your insurance questions or concerns

I have read and understand the above information. I certify that my insurance information is true and correct to the best of my knowledge 

I agree to notify you immediately of any change in my insurance coverage

I understand that I am ultimately responsible for the entire treatment fee. I agree to pay Busciglio Smiles any amount not paid by my insurance company

Patient Name

Responsible Party

Date: