PATIENT INFORMATION

DENTAL HISTORY

I hereby grant authority to the team at Samra Orthodontics to take orthodontic records which consist of a panoramic radiograph, cephalometric radiograph, digital study models, and intraoral/extraoral pictures. Records are needed for the orthodontist to accurately provide a diagnosis and treatment recommendations. I understand that more detailed information will follow for specific procedures prior to treatment being rendered.

I hereby assign Samra Orthodontics all dental benefits to which I am entitled. I hereby authorize and direct my insurance carriers to issue payments directly to Samra Orthodontics for dental services rendered to myself or my dependent regardless of my insurance benefits. Samra Orthodontics will provide an estimate of insurance coverage upon request. I understand that Samra Orthodontics is not responsible for inaccurate estimates. Payments of claims are not guaranteed by any insurance and are based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by insurance and I agree to pay any balance amount, in a timely manner.

I acknowledge I have received a copy of Samra Orthodontics Notice of Privacy Practices. I understand this notice explains how my protected health information is used and disclosed by the practice, and my rights regarding my protected health information.

I understand I should keep the Notice and refer to it if I have questions. I also understand I should contact Samra Orthodontics if I have a question or concern about my privacy rights.