Consent for Services

I (or authorized representative/guardian) hereby authorize Dr. Konz to take x-rays, study models, photographs and/or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's dental needs. Upon such diagnosis, I authorize Dr. Konz to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication. I hereby give Dr. Konz the absolute right and permission to use my photographs for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs.
I have read and understand the above information.
Patient, Parent or Guardian:
Date:

Consent for Financial Policies

We are committed to providing you with the best possible dental care. In order to begin a long lasting professional relationship, we ask for your understanding of and cooperation with our financial policies.
We ask that you realize that we don’t work for an insurance company. Rather we work 100% for you, our patient. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.
We will submit your claims and receive corresponding payments. You will be responsible for making any estimated copayments in full at the time of service. We will be happy to submit your insurance and collect payment from them provided we have verified eligibility. Any remaining balance after the insurance payment has been received will be due upon receipt of statement.
Financial alternatives for extensive dental treatment can be discussed and approved by our financial coordinator. These alternatives are not to be considered permanent arrangements.
OTHER IMPORTANT ITEMS
  1. When appropriate, we will be happy to submit a pre-treatment estimate to your insurance at your request after you have provided appropriate insurance information.
  2. Accounts exceeding 90 days since the last payment will be reviewed for collection by a third party. If you receive a statement you do not understand, please call us immediately. DO NOT IGNORE the statement. Communication is key to our relationship.
  3. If an account requires collection by a third party, all attempts to collect your debt will be done by the collection agency. We sincerely hope these measures will never become necessary.
  4. Unpaid insurance claims exceeding 90 days or after multiple attempts to file with the insurance carrier will become the patient's responsibility and you will be required to pay the balance in full.
  5. As of January 1, 2009, we no longer submit secondary insurance. We will provide you with the proper information but it is the patient's responsibility
  6. A $25 fee will be charged to your account for each missed appointment and appointments cancelled within 24 business hours. We appreciate your respect for other patients who can utilize your reserved time and your respect for our time. We extend you the same courtesy.
  7. There will be a $25 charge for all returned checks, payable by cash or credit card only. Checks which are not rectified immediately will be surrendered to a third-party collector for legal action.
If you have any questions concerning the above information, please do not hesitate to ask. We are here to help you!
I have read and understand the above information.
Patient, Parent or Guardian:
Date:

Consent for Use and Disclosure of Health Information

SECTION A: PATIENT GIVING CONSENT
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Email:
Social Security #:

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations of uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Officer: Jonathon Konz, DDS
Telephone: (703) 542-7000
EMAIL: info@littlesmilesashburn.com
Address: 42395 Ryan Road, Suite 108, Ashburn, VA 20148
Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Officer listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent.
SIGNATURE
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature:
Date:
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name:
Relationship to Patient:
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
INCLUDE COMPLETED CONSENT IN THE PATIENT'S CHART.
REVOCATION OF CONSENT
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities and health care operations.
I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.
Signature:
Date: