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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Scott Adams

Art Director

Scott Adams

Chief Executive Officer

Scott Adams

General Manager

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They Say

What our best client think for London.

Creativity is allowing yourself to make mistakes. Design is knowing which ones to keep.
Keep it simple idiot!

Scott Adams

If you see a few lines of atrocious code, you can make a judgement about the programmer. By judging the programmer, you can judge his boss.

Des Traynor

The whole essence of good drawing—and of good thinking, perhaps—is to work a subject down to the simplest form possible and still have it believable for what it is meant to be.

Chuck Jones

Work Porccess

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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

Contact Info

  • (225) 261-8050

  • 13323 Hooper Road
    Central, LA 70818

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