Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESPATIENT RESPONSIBILITY
The responsible party will be accountable for comprehending and complying with the information in this brochure. The patient or parent(s)/legal guardian(s) of a minor (under the age of 18) will be the responsible party. In the case of a minor of divorced parents, the parent/legal guardian bringing the minor to this office will be the responsible party, unless otherwise agreed to in writing.