For security purposes, we authenticate your identity using your wireless phone number or email address. You will receive a 4 digit verification code that will need to enter on next page.
Existing patient: Select a name for whom you want to edit details.
Note: We do not share or sell your data. The information you provide is encrypted and directly sent to our system and it is not stored online.
Yes
No
Disclaimer
I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.
Patient or Guardian Signature *
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Patient or Guardian Signature*
Yes No
A copy of our Notice of Privacy Practices was made available and I, [FName] [LName], acknowledge receipt of that notice.
Do we have your permission to transmit your information by conventional email to other offices for referrals or communication? There may be some level of risk that the information in these emails could be read by a third party. We currently use a HIPAA compliant encrypted email service.
I have had the 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 permision.
Patient, Parent or Guardian's Signature
Policies and ProceduresThank you for choosing Three Rivers Endodontics for your dental careneeds. Our office is committed to providing you with excellent care andcustomer service. In order to help with scheduling and other services, weask that you please familiarize yourself with our policies below.Office Policy
Appointment Policy
Financial Policy
Financial and Responsibility AgreementI grant permission to you or your assignee to telephone me at home or at myworkplace to discuss matters related to this form. I agree to let this office leave messages concerning appointment and/or results on my answering machine or with a family member. I also agree to let this office contact me via e-mail or text message.To the extent to determine liability for payment and to obtain reimbursement, I, the responsible party, authorize disclosure of portions of the patient's record. I hereby assign all dental benefits to which I am entitled, including MEDICARE, PRIVATE INSURANCE, WORKERS' COMPENSATION, and other health plans to Three Rivers Endodontics. This assignment applies to all charges outstanding as of the date of this signature and will remain in effect for all current and future charges until revoked in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am responsible for all charges whether or not paid by the insurance company unless dictated by the insurance company that there is a contractual write off. I hereby authorize said assignee to release all informationnecessary to secure payment.I have read and understand the Policies and Agreement of Three Rivers Endodontics which included the Office Policies, Appointment Policies, Financial Policies, and the Financial and Responsibility Agreement, and agree to abide by them.