DENTAL COSMETIC CENTER OF EDISON
906 Oak Tree
Avenue,Suite M,
South Plainfield, NJ 07080
908-222-3200
dental@dcc32.com
Policy
& Disclosures
Financial
Agreement
For
my convenience, this office may release my information to my insurance company,
and receive payment directly from them.I understand that if I begin major
treatment that involves lab work, I will be responsible for the fee at that
time. If sent to collections, I agree to pay all related fees and court costs.
Every effort will be made to help me with my insurance, but if they do not pay
as expected, I will still be responsible. I agree to pay finance charges of 1.5%
per month (18% APR) on any balance 90 days past due.I will pay a fee for
appointments broken without 24 hours notice.Treatment plans may change, and I
will be responsible for the work actually done.
I
will be responsible for any charges not covered by insurance and my balances for
services provided at Dental Cosmetic Center of Edison
I
agree to let Dental Cosmetic Center of Edison run a credit report if I
am interested in doing payment plan for outstanding balance or agreed upon
treatment plan. If no, then all fees are due at time of service.
HIPPA/Notice
of Privacy
Our
office will condition treatment, payment, enrollment or eligibility for benefits
on whether you sign this authorization. The purpose for which our office is
requesting your authorization is to diagnose and complete treatment. The
information to be disclosed would include your protected health information. The
information may be disclosed to, but not limited to, laboratories, hospitals,
insurance companies, medical and dental referrals, other health care
professionals, education purposes, dental clearinghouse companies, collection or
billing agencies, companies we are contracted with for business operations and
employees of this office. This form also authorizes the use of photography as a
diagnostic tool. By agreeing to this authorization, you understand that the
potential for information disclosed pursuant to this authorization may be
subject to subsequent disclosure by the recipient and no longer protected by the
privacy regulation of HIPAA.
I
have had full opportunity to read and consider the contents of the Notice
of Privacy Practices. I understand that I am giving my permission to your use
and disclosure of my protected health information in order to carry out
treatment, payment activities, and healthcare operations. I also understand that
I have the right to revoke permission.
Social
Media & Marketing Consent
I
give permission to Dental Cosmetic Center of Edison/Dental Cosmetic Center to
use my name, information, statements, or photograph for public relations
purposes, and to attribute my statements to me as an expression of my personal
experience. I understand that this information may be used in dental
journals, website(s), media articles, social media, advertisements or other
marketing materials that promote Dental Cosmetic Center of Edison/Dental
Cosmetic Center. I also agree that no material needs to be submitted to me for
any further approval, and I give Dental Cosmetic Center of Edison/Dental
Cosmetic Center the right to copyright such material if necessary. I understand
that if I don't grant this permission, it will not affect my eligibility for
receiving services through Dental Cosmetic Center of Edison/Dental Cosmetic
Center, and will notify my request to opt out by emailing dental@dcc32.com on future use.