700 route 130 N Suite 204 Cinnaminson, NJ 08077
Please fill out page 3 if you have additional dental insurance
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Dr. Mock In Huh all insurance benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above name dentist may use my health information and may disclose such information to the above named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.
Payment is due in full at the time of treatment unless prior arrangements have been approved
I understand dental treatment has potential risks and consequences. Likewise, so does the refusal or denial of dental treatment. Untreated conditions may lead to pain, swelling, infection, tooth loss and/or other severe consequences. I understand that dentistry is not an exact science and that no exact results can be assured or guaranteed. I have had the opportunity to have all of my questions answered by my dentist.
You may refuse to sign this acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I have received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
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 operation. I also understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.
Please understand that at Rapha Dental, your dental appointment reserves valuable professional time, not only our doctor but with our entire staff. Your appointment time is reserved exclusively for you so that we can provide you with our undivided attention.
We respect the value of your time and kindly request that you respect and value our time as well. Because of the individual nature of each appointment, a 48 hour notice is required for any cancellation or changes that may be required to your appointed time.