Do Not Bill to Dental Insurance Form- Hitech Act -42 USC 17935- free patient dental forms

A patient request not to send certain health information to their dental insurance, citing Section 13405 of the HITECH Act (42 USC 17935) as stated in the file. The restricted services are listed as all non-covered, disallowed, or upgraded treatment. The patient confirms they have dental coverage, chooses not to submit a claim for those services, releases the provider from plan obligations, and confirms the services and payment options were explained.

Use it when a patient wants to pay out of pocket for a service and keep it off their insurance record. The front desk or financial coordinator reviews it with the patient, collects a signature before treatment, and flags the account so no claim is filed.