I authorize the release of my dental records from Drs. Culberson, Mulliken or Rutherford to individuals involved in my dental care. I further authorize the release of records from any individuals to Drs. Culberson, Mulliken or Rutherford,
I authorize insurance payments to be made directly to Drs. Culberson, Mulliken or Rutherford. I understand that Iam responsible for any unpaid balance.
I am aware that should I not provide adequate notice to change an appointment, I may be charged a fee. (7 business days for a surgical appointment and 2 business days for a cleaning appointment).
I am aware of and have received notice of the Health Insurance Portability and Accountability Act (HIPAA).
NOTICE OF PRIVACY PRACTICES—ACKNOWLEDGEMENT
We keep a record of the health care services we provide for you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting us.
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you may access your information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
AUTHORIZATION FOR APPOINTMENT CONFIRMATION
As a courtesy to our patients, we often will give a variety of appointment reminders. Some of these reminders may generally include, but are not limited to, appointment post-cards sent through the mail, messages left with roommates/family members, and voicemail messages. Usually within these reminders a certain amount of specific and detailed information, consisting of the patient's appointment time and date, or need for an appointment may be included.
By my signature below, I authorize the offices of Drs. Culberson, Mulliken or Rutherford and their staff to confirm my appointments and remind me of the need for an appointment in the above-mentioned ways, for the duration of my treatment with their office.