Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. By agreeing to this consent, you permit the release of any information to or from your dental practitioner as required including a full report of examination findings, diagnosis and treatment program to any referring or treating dentist or physician. You understand that you are financially responsible for all charges whether or not paid by insurance. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services. INSURANCE POLICY The Craniofacial Pain Center of Georgia does not file or accept assignment from medical insurance companies, due to many reasons such as: inconsistencies in benefit information, extreme delays in payment, multiple denials of a claim for no legitimate reasons, do not pay directly to our office since we are not a network provider. We need to inform you that you are entering into a relationship with the doctor in which the doctor agrees to treat the patient and the patient agrees to pay the doctor’s fees for that treatment. The insurance company has NO relationship with the doctor. As a courtesy to you, we will prepare two copies of a “Doctor’s Statement of Services” and any supporting documentation that we feel the insurance company may need for each visit with us for which there is a charge. You will then fill out the employees portion on your insurance carriers medical claim form and attach the “Doctor’s Statement of Services” and any other documentation to your form and send it to your insurance company for them to send any benefits to you. Always keep one copy for your records. Any additional information needed to process your claims will be provided upon request from the insurance company. We suggest to all patients that they contact their insurance company to find out their TMJ benefits, policies and limitations. Remember, insurance companies give estimates and benefits over the phone, however they are ONLY estimates and are not always accurate or a guarantee of reimbursement. FINANCIAL POLICY Fees are paid as services are rendered. We accept all major credit cards, VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS and or CASH. Payment plans for the estimated treatment may be made with Care Credit Services upon prior approval of your credit application. Several payment options, (with and without interest) are offered. I will pay for services rendered on the date of service. I acknowledge that I have read this form and that I fully understand its contents that I have been given ample opportunity to ask questions and that all questions have been answered satisfactorily. THIS IS NOT A CONTRACT NOR AN AGREEMENT TO SEEK TREATMENT