3029 Avenue V, Brooklyn NY 11229
1985 Ocean Avenue, Suite 1-D, Brooklyn, NY 11230-6815
** You May Refuse to Sign This Acknowledgement**
OR FILL OUT THIS FORM ONLINE
I, , have received a copy of this office's Notice of Privacy Practices
Please Print Name:
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not by obtained because:
FOR INDIVIDUALS WITH DENTAL INSURANCE: PLEASE READ THE STATEMENT BELOW
This office is happy to cooperate with individuals who are covered by dental insurance. We only ask that you carefully read your policy to be sure that you are fully aware of any restrictions that apply to the benefits provided. Dental insurance is a contract between the patient and the insurance company for reimbursing the cost of dental services. It is not a contract between the dentist and the insurance company.
I understand that I am financially responsible for all services rendered by the dentist. I understand any co-payments, deductibles, and/or procedure cost not covered or denied by my insurance company (including coverage termination prior to the date services are rendered), are my responsibility. This dental office is authorized to fill out and/or assist me to complete any and all insurance forms pertaining to services rendered.
Patient Signature: (or Parent/Guardian signature for patient under 18 years of age)
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental srvices and materials not paid by my dentalbenefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.
Patient/Guardian Signature Date
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.