Use of protected health information
Describes
how we may use and disclose your
protected health information to carry
out treatment, payment or health care
operations and for other purposes that
are permitted or required by law.
For first-time patients
Required to
be filled out by all new patients coming to the practice for the
first time.
Please fill this form and bring along with you during your
first visit.
Patient's Medical History
Required to
be filled out by all new patients coming to the practice for the
first time.
Please fill this form and bring along with you during your
first visit.
For
children's treatment
Authorization
given by an adult to agree for the treatment of a child.
Please fill out this form and bring with you when bringing in a
child for treatment.
Use of protected health information
This form allows us to file your insurance on your behalf with
your consent to disclose this information to the insurance
company and any involved third party.
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DISCLAIMER OF Gainesville Family
Dentistry
Gainesville Family Dentistry expressly disclaims all
warranties and responsibilities of any kind, whether express or
implied, for the accuracy or reliability of the content of any
information contained in this Web Site, and for the suitability,
results, effectiveness or fitness for any particular purpose of the
services, procedures, advice or treatments referred to herein, such
content and suitability, etc., being the sole responsibility of
parties other than Gainesville Family Dentistry and the reliance
upon or use of same by you is at your own independent discretion and
risk.
