Arthur O. Lyford, DMD, PLLC ~ 3 Market Pl, Unit D ~ Hollis, NH ~
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1 Arthur O. Lyford, DMD, PLLC ~ 3 Market Pl, Unit D ~ Hollis, NH ~ Arthur O. Lyford, DMD, PLLC 1
2 Arthur O. Lyford, DMD, PLLC 2
3 Arthur O. Lyford, DMD, PLLC 3
4 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION I,, hereby authorize Arthur O. Lyford, DMD, PLLC to share information regarding all my dental treatment to the person(s) listed below: Name: Relationship: Phone: Name: Relationship: Phone: This authorization is in effect until I notify Dr. Lyford in writing. I understand that if I cancel my authorization, I will still be able to receive any treatment, as long as this information is not needed to determine if I am eligible for services or to pay for the services that I receive. Shared information may include all or part of my dental history, dental treatment plan, and financial plan. I realize that some or all aspects of my medical health and medical history may be revealed and/or discussed as it is necessary to consider this aspect of my health in relation to my dental needs. I authorize the use or disclosure of my individually identifiable health information as described above. I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed. I have the right to receive a copy of this authorization. I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization. I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the dental information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. Arthur O. Lyford, DMD, PLLC 4
5 For your convenience we offer the following methods of payment in full at each appointment: Cash - Personal Check - Visa - MC - Amex - Discover We will also complete a complimentary benefits check as well as submit pre-authorizations to your insurance company. We submit all insurance at time of service electronically. I understand that my dental insurance is an agreement between my insurance company and me, that I am responsible for the total fees at time of service regardless of my insurance. I understand that responsibility for payment for services provided for myself or my dependents is mine, due and payable at the time services are rendered. Our office requires 48 hour notice for any canceled appointments to avoid a $125 cancellation fee. There will be a $50 charge for all returned checks. A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days. If your account is sent to collections you will be responsible for any and all costs involved in the collections process. This will include all court costs, attorneys fees, and correspondences. Print Patient Name Patient/Guardian Name & Signature Date Clinical Staff Name/Signature Office Use Only Arthur O. Lyford, DMD, PLLC 5
6 ARTHUR O. LYFORD, D.M.D., P.L.L.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Arthur O. Lyford, DMD, PLLC -- 1 of 3 (2/3 Notice of Privacy Practices HIPAA Compliance)
7 Arthur O. Lyford, DMD, PLLC -- 2 of 3 Notice of Privacy Practices HIPAA Compliance
8 ~ The ART of Dentistry, Arthur O. Lyford, DMD, PLLC ~ 3 Market Pl ~ Hollis, NH ~ Arthur O. Lyford, DMD, PLLC -- 3 of 3 Notice of Privacy Practices HIPAA Compliance
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