All new patients will need to complete a Referral Form, Consent for Sedation (if Oral or IV sedation is required for dental appointments), Consent for Treatment, Acknowledgement of Privacy Practices, Records Release Consent and a Title VI form. The Title VI form is only necessary for patients who are part of the Medicaid Waiver. If a patient has a legal conservator, the consent forms will need to be signed by the conservator. If a patient is under 18, the consent forms will need to be signed by the patient’s legal guardian. Every patient will need an updated Consent for Treatment or Sedation (if required) annually. Every patient who is part of the Medicaid Waiver will also need an updated Title VI annually.  For your convenience, forms can be found here. You will need to download and complete the forms. Once completed, the information may be submitted via e-mail to records@triaxdental.com or fax to 615-915-6091.

Forms:

Referral

Consent for Sedation and Treatment

Consent for Treatment

Notice of Privacy Practices

Acknowledgment of Privacy Practices

Consent for Records Release

Title VI