I affirm that the information I have given is correct to the best of my knowledge. It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental service I may need.

I understand that I am responsible for payment of all services rendered, but as a service to me this office will submit dental claims. I assign to Daher Dental and associates all insurance benefits otherwise payable to me. I authorize them to release all information necessary to secure the payment of benefits, and authorize the use of this signature on my insurance submissions, whether manual or electronic.

Payment is due at time of service.

I have received Daher Dental’s Notice of Privacy Practices, written in plain language. It sets out the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice’s legal duties.

The notice includes:

• This practice is required by law to maintain the privacy of protected health information.
• This practice is required to abide by the terms of the notice currently in effect.
• The types of uses and disclosures this practice may make for treatment, payment and health care operations.
• Each other purpose for which this practice may use or disclose protected health information without my written consent.
• Uses and disclosures that are prohibited or materially limited by law.
• Uses and disclosures made only with my written consent, which I may revoke.

My rights with respect to that information:

• To complain to this practice and the Secretary of HHS if I believe my privacy rights have been violated, with no retaliation.
• To request restrictions on certain uses and disclosures of my protected health information.
• To receive phone calls and text message reminders, and information about my treatment, payment and insurance.
• To receive confidential communications of protected health information.
• To inspect and copy protected health information.
• To amend protected health information.
• To obtain a paper copy of this practice’s Notice of Privacy Practices on request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information it maintains. I understand I can obtain the current notice on request.