DR. BRAD SORENSON | DR. LEVI MILLER
1708 S. Clover Drive | MOSES LAKE, WA

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(509) 761-6568

 

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Responsible Party (if someone other than patient) Fields marked with * are required

Insurance Information Fields marked with * are required

Secondary Insurance Information Fields marked with * are required

Health History Fields marked with * are required

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Terms And Conditions Fields marked with * are required
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for dental services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered unless financial arrangements have been made. I authorize my insurance benefits to be paid directly to the dental office. I also authorize the dental office or insurance company to release any information required for this claim. I understand that I am responsible for any fees not paid by insurance and that a credit report may be obtained if necessary. I also understand that a $50 - $100 fee will be charged for missed appointments. This charge is not covered by insurance. I understand that if I need to change an appointment time a 24-hour notification is necessary to avoid this fee. It is also clear to me that no further appointments can be scheduled until this fee has been paid. Additional charges may be incurred in the case of multiple missed appointments.                    

Release Authorization Fields marked with * are required

HIPAA and Privacy Practices Consent Fields marked with * are required
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.                    

Signature Fields marked with * are required
Date: 10/16/2021