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Insurance Information

Patient Details
Insurance Details
Privacy Information
  1. In accordance with the Privacy Regulations created by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we are required to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information that describes how we may use and disclose your protected health information to carry out treatment, payment of health care operation and for other purposes that we are permitted or required by law.

    We will use and disclose your protected health information to provide, coordinate, or manage your dental care and any related services. For example: your health/dental information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information periodically to another dentist, physician or health care provider who becomes involved in your care.

    We may use and disclose dental information about you in order to obtain payment for services rendered. Such disclosures may be made to you, an insurance company, responsible party or third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover treatment.

Fee Information
  1. All fees are ultimately the responsibility of the responsible party.

    Medical, Share-of-Cost Medi-Cal, Patient Trust accounts or Private Dental Insurance may be billed for Dental Hygiene Treatment. Fees for service rendered will be due and payable upon the completion of treatment. Third-party (insurance) payment will be disbursed directly to the patient or responsible party.

  1. By submitting this form, permission is authorized for direct payment to HygentleCare for Medi-Cal and Share-of-Cost Medi-Cal disbursements.
  2. Medi-Cal coverage for dental hygiene treatment is usually once per full 12 month period. Special conditions and/or medications may determine more frequent treatment. By submitting this form, permission is granted to use Medi-Cal Share-of-Cost funds.
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