One Good Smile
929 W. Wise Rd.
Schaumburg, IL 60193
Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. We are allowed to release this information to your insurance company or as necessary to get paid for our services. You can have access to your records by simply asking.
By agreeing with this consent form, you permit the release of any information to or from your dental practitioner as may be required.
You certify that you, and/or your dependent(s), have insurance coverage as submitted on the following registration form and assign directly to your dental practitioner all insurance benefits, if any, otherwise payable to you for services rendered. You understand that you are financially responsible for all charges whether or not paid by insurance. You authorize the use of your signature on all insurance submissions. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services.
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