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COMPLETE LIST OF FORMS
GENERAL INFORMED CONSENT
SPECIALTY CONSENT
PROPHYLAXIS & PHOTOGRAPHY
TREATMENT REFUSAL
PATIENT DISMISSAL, CLAIMS RELEASE
EMPLOYEES
ANNUAL FORMS PACKAGES
INFORMED CONSENT LAW
CONTACT
SECURE ORDERING
REQUEST A FORM
DISCLAIMER, LICENSE, & LIABILITY LIMITS
PATIENT EDUCATION, REGISTRATION
CONSCIOUS SEDATION FORMS
HIPAA COMPLIANCE
DENTAL OFFICE & EMPLOYEE MANUALS
EMERGENCY PROTOCOL
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PATIENT DISMISSAL, CLAIMS RELEASE
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Patient Dismissal & Release of Claims:
Patient Dismissal Letter
$10.00
Patient Dismissal Letter:
For dentist's office letterhead, formatted with apprpriate language for dismissal of a patient from practice, which may be used in conjunction with particular state rules or statutes {please check your jurisdiction for compliance requirements]. Advises patient of current oral status, and availability for 30 days for emergencies.
Release of Claims
$10.00
Patient Release of All Claims:
Release form for settlement of dispute between patient and provider, stating that
"payment constitutes a final and full settlement of any claim I might have against the dentist in this particular case,..."
Patient Authorization to Release Dental Records
$10.00
Patient Authorization to Release Dental Records
- Complies with federal HIPPA restrictions on the release of patient health information.
Also, in Texas, is compliant with TSBDE Rule 108.8, which states that a patient is entitled to a complete copy of their dental records upon request.
