Orthodontic Associates of New Canaan PLLC
Mike Cotzas D.D.S.

45 Pine Street
New Canaan, CT 06840
(203) 966- 3042

Diplomate, American Board of Orthodontics

Patient Consent for Use and Disclosure of Protected Health Information

I HEREBY GIVE MY CONSENT FOR DR. COTZAS OFFICE (REFERRED TO AS “OUR OFFICE’) TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT ME TO CARRY OUT TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS (TPO). THE PRIVACY NOTICE PROVIDED BY DR. COTZAS OFFICE DESCRIBES SUCH USES AND DISCLOSURES MORE COMPLETELY.

I have the right to review the Privacy Notice prior to signing the consent. Our office reserves the right to revise the privacy notice at any time. A revised privacy notice may be obtained by forwarding a written request to our privacy officer.

With this consent, our office may call my home or other alternative locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items, and any calls pertaining to any clinical care, including laboratory test results, among others.

With this consent, our office may mail to my home other or other alternative locations any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements.

With this consent, our office may email to my home or other alternative location any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements. I have the right to request that our office restrict how it uses or discloses my PHI to carry out treatment, payment, and health care operations. This practice is not required to agree to any requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow our office to use and disclose my PHI as set forth in the Privacy Notice to carry out treatment, payment, and health care operations.

I may revoke my consent in writing except to the extent that the practice has already made disclosures reliant upon any prior consent. If I do not sign this consent, or later revoke it, our office may decline to provide treatment to me.

Signature of Patient or Legal Guardian

IMPORTANT OFFICE POLICIES AND FEES

Please read and sign this form. If you have any questions, please ask our front desk staff. Thank you.

  • Office hours are Monday through Thursday 8:00 am to 6:00 pm. Friday office hours are 9:00 am to 5:00 pm for patient emergencies and administrative purposes only.
  • If I need to cancel or reschedule an appointment, I understand that I must give the office at least 24-hour advance notice.
  • I understand that Dr. Cotzas does not accept insurance and I am fully responsible for the fees incurred. Payment is due at the time services are rendered and a “superbill” will be generated with all necessary information that the patient may submit to their insurance for reimbursement. If an installment plan is in place, I understand that I will be responsible for making the monthly payment by the 15th of every month otherwise I will be subject to a $15.00 late fee for each month the payment is delinquent.
  • I understand that Dr. Cotzas office requires all appointments to be confirmed one business day prior to the scheduled appointment. Confirmation texts and emails are sent out one or two business days prior to the appointment so please reply to them with a yes or no answer. If we do not receive a reply text or email confirmation for the appointment, a phone call will then be made to you for the confirmation. If we do not receive a response at least 24 hours before the appointment, we reserve the right to cancel the appointment and give it to another patient.
  • I understand that if a non-urgent message is left at the office after 6:00 pm Monday through Thursday, the call will be returned the next business day after 8:00 am. If a non-urgent message is left after 5:00 pm Friday, anytime Saturday, Sunday or on a holiday, the call will be returned the next business day after 8:00 am.
  • When Dr. Cotzas is out of the office, there is always a local orthodontist on call for emergencies. When calling our office, the answering machine will identify that orthodontist and their phone number. Kindly leave a message on our machine stating the emergency but also call the covering doctor who will be happy to take care of the emergency for you.
  • It is important that all patients bring any and all appliances (that are part of their treatment) with them including headgear and retainers. We will provide rubber bands, retainer cases and wax as needed.

By signing this form, I give the office of Dr. Mike Cotzas consent to call my home or cell phone and leave a message on voicemail or in person as well as send emails and/or text messages to the address I provide in reference to any items that assist the practice in carrying out treatment, payment, and healthcare operations, such as appointment reminders or any calls pertaining to my child’s or my clinical care. I have the right to request that the office restrict how it uses or discloses my PHI to carry out treatment, payment, or health care operations. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I understand and agree to all the above.

Parent/Patient Signature