I certify that the above information is complete and accurate to the best of my knowledge. I hereby authorize MI Smiles Dental and staff to take x-rays, photos, and other diagnostic aids as deemed appropriate by the Doctor to make a thorough diagnosis of my needs. I fully understand that using anesthetic agents embodies certain risks. I understand I may ask for complete recital of any complications. I have received a copy of this office’s HIPAA policy or had the opportunity to do so. Lastly, I agree to be responsible for payment of services rendered on myself and my family. I understand payment is due at time of service unless other arrangements have been made. If payments are not paid by agreed dates, I understand a 12% finance charge may be added on my account. I understand that the insurance carrier may pay less than the actual bill for services.
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. If a medical emergency arises in office, a complete medical history is needed to provide you with the best care and efficiency. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
No Insurance?No Problem!