I grant my permission to HQ Prosthodontics, PA to upload and store confidential patient information - including account information, appointment information and clinical information - to the secured web site for HQ Prosthodontics, PA. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand HQ Prosthodontics, PA and myself are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that HQ Prosthodontics, PA is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand HQ Prosthodontics, PA is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the HQ Prosthodontics, PA web site with my ID and password. I also agree to immediately notify HQ Prosthodontics, PA of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand HQ Prosthodontics, PA will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that HQ Prosthodontics, PA has the right to monitor, retrieve, store, upload and use my patient information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand HQ Prosthodontics, PA will use commercially reasonable efforts to maintain the confidentiality of all patient information that is up loaded to the web site on my behalf.
We, HQ Prosthodontics, PA, offer the convenience of an on-line payment service as part of our on-going program to better serve our patients. You may apply a specific amount toward your outstanding balance using a major credit card, debit card or check. You remain responsible for any charges and accrued interest on all late payments.
Each time you initiate a transaction, you authorize us or our agent to draw a check or draft or initiate an automated clearing house (ACH) or depository transfer check (DTC) debit in your name to the financial account you specify in the amount you request, payable to us or to our agent, in the amount of the transaction. For each transaction your bank may assess its customary per-check or item-handling charge, if any. You also agree to pay us a service charge for each dishonored check or draft to reimburse us for any costs of collection. Your bank may also assess its customary charge for such items.
While you may apply payment toward an outstanding balance today the payment may not be posted to your account for five business days. Please call our office if you require assistance.
I understand HQ Prosthodontics, PA CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
I have read and understand the information above regarding the secured uploading of patient information to the web site and the acceptance of payments for HQ Prosthodontics, PA.
We are delighted to welcome you to our practice and are pleased that you chose us to serve your dental needs.