Complete this section ONLY if the insurance subscriber is not the patient, and if you are the patient’s parent/guardian.
By checking the box below, you agree to the following:
I authorize my insurance company to pay the dentist all insurance benefits for services rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges, whether or not covered by insurance.
I understand that I may inspect or obtain a copy of the protected health information described in this authorization.
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I understand that this authorization may be revoked at any time by submitting a written revocation to the office that received this authorization. I also understand that such revocation will not apply to records already released under this authorization or to actions already taken in reliance on it.
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I understand that my health care and the payment for my health care will not be affected if I choose not to sign this form.
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I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state confidentiality laws.
I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information, and clinical information) on the secured website for the dental practice.
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I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand that both the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me, and that the dental practice is not liable for any charges, damages, or losses that may occur as a result of my failure to maintain confidentiality.
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I understand that the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization allowing another person or entity to access and use the dental practice website with my ID and password. I agree to immediately notify the dental practice of any unauthorized use of my ID or of any need to deactivate my ID due to security concerns.
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I further understand that State and Federal laws, as well as ethical and licensure requirements, impose obligations with respect to patient confidentiality that may limit the ability to use certain services or to transmit certain information to third parties.
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I understand that the dental practice represents and warrants that it will, at all times during the term of this Agreement and thereafter, comply with all laws directly or indirectly applicable to the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and will use its best efforts to ensure that all persons or entities under its direction or control also comply with such laws.
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I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information.
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I understand that the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information uploaded to the website on my behalf.
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However, I also understand that the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THE SITE OR THE SERVICES.