The signature affixed below authorizes examination and treatment by the dentists, and/or their staff, and further, use of those procedures
which in the judgment of the doctor are necessary during the delivery of dental care.
I understand that McIlwain Dental Specialists may not be a contracted provider for my insurance company and that MDS will be filing to my
insurance company as a courtesy and expect their payment in 30 days. I recognize that it is my responsibility to pay any deductible amount,
co-insurance, or any other balance not paid for by the insurance company.
I hereby assign all dental and/or surgical benefits to include the major medical benefits to which I am entitled, including private insurance
and other health plans to McIlwain Dental Specialists. This assignment will remain in effect until revoked by me in writing. A photocopy of
this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid
by said insurance. I hereby authorize and assign to release all information necessary to secure payment.
Authorization and Release
I certify that the above questions have been accurately answered and the information is correct to the best of my knowledge. Our Notice of
Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains a
Patients Rights section describing your rights under the law. You have the right to review our notice before signing this consent. The terms of
our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment, or
health care operations. We are not required to agree to this restriction, but if we do we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health
care operation. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any
disclosures we have already made in regards to your prior consent. The practice provides this form to comply with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).