Patient Information

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Primary Inusrance

• I authorize my insurance company to pay Dr. Vaughan all insurance benefits otherwise payable to me for services rendered.
• I authorize the use of this signature on all insurance submissions.
• I authorize the dentist to release all information necessary to secure the payment of benefits.
• I understand that I am financially responsible for all charges whether or not paid by insurance.
• I hereby cerfify that the medical information on this form is accurate to the best of my knowledge.
• If there are any future changes in this information, I will inform Dr. Vaughan's office of these changes.

By submitting this form, you acknowledge that this document has been completed accurately and truthfully. I give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review the practice/clinic's Notice of Privacy Practices (for a more complete description of uses and disclosures) before submitting this form. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agress to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

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Contact Doctor Walter Vaughan
& The Central Smile Team

Mon - Thurs: 8am - 5 pm
Friday: 8am - noon
Out to lunch from 12 - 1:30 pm

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