Privacy Practices

I certify that I have read and understand the attached information to the best of my knowledge. The attached questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the record of any treatment or examination rendered to me or my child during the period of such dental care to a third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand it is the policy of this office to collect all co-pays at the time treatment is rendered. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all rendered on my behalf or my dependents.
Name*
First Last
Email*
Signature of Patient (or parent/guardian if minor)*

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I have been given a copy of your Notice of Privacy Practice prior to signing this consent. I understand that this organization has the right to change it's Notice of Privacy Practice from time to time and that I may contact this organization at any time at the address above to obtain a current copy. I understand that, under the Health Insurance Portability & Accountability Act 9f 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. 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.
Patient Name*
First Last
Email*
Signature*

Neil J. Bueker, D.D.S.