TODD GENTLING, DDS 1100 East Lansing Street, Broken Arrow, OK 74012 918-251-8141
TODD GENTLING, DDS
1100 East Lansing Street, Broken Arrow, OK 74012
918-251-8141
Dental insurance plans have exclusions, these help to keep premiums as low as possible for your employer. This makes your dental plan a supplemental coverage for your dental needs, and not designed to cover your treatment in its entirety. Dr. Gentling’s goal is to identify, recommend and treat your dental needs in your best interest.
We do require that if patient is a child under the age of 18 a parent or guardian must accompany patient for all appointments for consent of treatment.
I hereby authorize and give consent for payments to be made directly to BA-dentist.com. I understand that I am responsible for all dental treatement costs regardless of any insurance coverage. I hereby authorize BA-dentist.com to administer medications and perform diagnostic, photographic and therapeutic procedures as may be necessary for my proper dental care. All information provided by me on my patient information, health history and dental history forms are correct to the best of my knowledge. I grant the right to BA-dentist.com to release my dental/ medical and patient information to third party payers and/ or other health professionals. I understand BA-dentist.com works with the District Attorneys office when fraudulent funds are issued Services charges may apply to my account in addition to any NSF Check Fee. In the case of default of payment, I promise to pay any legal interest on the balance due, together with collection costs and just attorney fees incurred to collect on my account or future outstanding accounts.
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I certify to the above statements regarding my medical and dental conditions that the information provided is complete and accurate.
Thank you for choosing BA-dentist.com. We want your visit to be pleasent and comfortable.
Information Received
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from the third party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the notice. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I hereby grant BA-dentist.com permission to contact me and leave messages pertaining to my dental care (including calling to remind me of appointments, to inform me of referral appointments, test results, prescription information, etc.) by a recording device or with the following persons (please consider listing spouse, parents, step-parents, grandparents, children, secretary, etc)
This consent will remain in effect throughout our dentist-patient relationship unless withdrawn in writing by patient. I am aware that signing this form may cause disclosure of confidential or privileged information to those designated by me. I have been given the opportunity to read the consent and receive clarification of any questions I may have, and to obtain a copy.
I have had an opportunity to review a copy of BA-dentist.com office policies. I understand that I may request a copy. Information included the following:
1. How we work with insurance companies
2. Payment Options
3. 48 hour Cancellation Policy
4. Confirmation of Appointments
I may refuse to sign this acknowledgement.
I have received a copy of Dr Gentling’s Notice of Privacy Practices.
I consent for the office of Dr Gentling to share my personal information with the following: (family, friends, etc)