Thank you for choosing us as your dental health care provider! We are committed to giving you exceptional dental treatment. In order to better assist us in this endeavor, please read this agreement carefully.
HIPAA RELEASE OF PRIVATE HEALTH INFORMATION: We are unable to discuss your treatment with anyone unless you give us permission. By signing this form, you indicate that you authorize the release of information including the diagnosis, records, images, examination findings and claims information in order to assist in filing your insurance claims and gathering benefit information.
HIPAA RELEASE OF PRIVATE HEALTH INFORMATION FOR OTHER PARTIES: The above information may also be released to other parties at your request, such as a spouse or family member. Please notify our office in writing if you wish to allow us to speak to another party on your behalf.
If at any time Dr. Reeves feels it necessary to refer care to a specialist (such as an oral surgeon, endodontist, periodontist, etc.), I authorize Rebecca Reeves, DMD to forward any records or information necessary to assist in my care to the recommended practice.
DIGITAL COMMUNICATIONS: I consent to Dr. Rebecca Reeves contacting me electronically by the email address and/or cell phone on file for the purpose of receiving appointment reminders, notification that I need to make an appointment, dental records, survey regarding dental visit, or reminders of uncompleted treatment.