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    Align Clinic, LLC

    Consent to Treatment/Assignment of Benefits/Authorization to Release Information/Receipt of Privacy Practices,

    Medicare Standards, and Patients’ Rights Policy


    I hereby consent to treatment in accordance with my doctor’s prescription.

    I hereby certify that I have received a copy of the “Notice of Privacy Practices” which describes how Align Clinic LLC may disclose my protected health information in carrying out my treatment, collection of my bills, or health care operations and for other purposes that are permitted or required by law.

    Align Clinic LLC reserves the right to change the privacy practices that are described in its Notice of Privacy Practices. Align Clinic LLC also reserves the right to apply these changes retroactively to PHI received before the change in privacy practices. I understand that I may obtain a revised Notice of Privacy Practices by calling Anthony New II at (650) 375-2231 and requesting a revised copy be sent in the mail or by asking for one at the time of my next appointment.

    I received Medicare’s 30 Supplier Standards by which our facility has agreed to abide, and I received Align Clinic’s Patients’ Rights Policy.

    I hereby authorize Align Clinic, LLC to release necessary medical information to my insurance carrier(s) to process my medical claim. I also authorize my insurance carrier to pay benefits directly to Align Clinic, LLC. I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made payable to Align Clinic LLC for any covered services furnished by Align Clinic, LLC. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents in order to determine these benefits or benefits for related services.

    I understand and agree that I am responsible for the following expenses: any service my insurance plan deems "non-covered", all coinsurance and/or co-payment amounts, all deductibles, any amount that exceeds benefit limits under my insurance plan and any amount my insurance plan deems not covered because I was not insured on the date of service.


    While not a direct violation of federal HIPAA law, it is important for you to know that there is a risk in sending any email which is unencrypted or deemed "unsecure." However, many patients find email a convenient form of communication with our office. Although unencrypted email is not considered secure, some patients/parents appreciate the tradeoff between ease of use/convenience and security. We want to accommodate your preference. We will adhere to it unless you express a change in writing, which you are welcome to do at any time. Please indicate your preference with the appropriate checkbox below:



    * A copy of the “Notice of Privacy Practices” is available upon request


    Please check that all information is completed and try to submit the form until you receive a successfully sent message, thanks.

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