New Patient Information Form

I certify this information is true and correct to the best of my knowledge. Des Moines River Dental Care has my authorization to adhere to my consents outlined on this form. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment.

I give permission to Des Moines River Dental Care to share my dental history, recommended treatment, and balance info with anyone that I have listed in the Spouse, Parent, or Other fields.

I understand that under the Health Insurance Portability & Accountability act of 1996(“HIPPA”), I have certain rights to privacy regarding my protected health information(PHI). 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 the treatment, directly and indirectly
– Obtain payment from third-party payers
– Conduct normal healthcare operations such as quality assessments and physician certifications

I received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. 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 to obtain a current copy of this Notice of Privacy Practices.