Assignment and Release

I certify that I (or my dependent) have insurance coverage and assign directly to Patrick J. McCoy, DDS all insurance benefits, if any, for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

I acknowledge that I have been offered a copy of the Statement of Privacy Practices for the office of Patrick J. McCoy, DDS. The Statement of Privacy Practices describes uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The posted Statement of Privacy Practices describes my rights and the responsibilities of this office with respect to my protected health information.

Patrick J. McCoy, DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If changes occur I will be offered a revised copy at the first visit after the revision is made.

Additional Disclosure

In addition to the allowable disclosures described I authorize disclosure of my protected health information to the persons indicated below.

This office has a 48 business hour cancellation policy. If you miss or late cancel your scheduled dental appointment you will be charged a $50 fee per appointment.