Note to client
Your consent is required. This means that we want you to understand the services we hope to provide to you, the cost involved, and what we do with the personal information we obtain about you. If you have any questions regarding our privacy policy, please ask.
Consent for Personal Information
I understand that to provide me with denture health care goods and services, the denturist will collect some personal information about me such as, but not limited to, home address, telephone number, medical history, and photos.
I understand that in accordance with this denturist’s Privacy Policy, the collection and disclosure of my personal information will be protected and remain within the scope of this denturist’s practice and in relation to the provision of denture health care.
I understand how this policy applies to me, and I have been given a chance to ask.
Any questions I have about the Privacy Policies, and they have been answered to my satisfaction.
I understand that the signature on this form will be kept on my file. I, the undersigned, hereby certify the information given by me to be accurate.
Consent to Submit Claim Electronically
I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I hereby assign my benefits, payable from claims submitted electronically to Monica Johnson, DD, and authorize payment directly to her. This authorization shall continue in effect until the undersigned revokes the same.
