The standard of practice requires you to ensure that the patient is fully informed of the possible consequences of refusing necessary care. Dentists must obtain informed consent for every treatment you propose and perform on patients or from the patient's legal guardian or decision-maker.I am being provided with this information and refusal form so I may better understand the treatment recommended for me and the consequences of my refusal. Directions: After youth signs, enter the Youth Health Services Refusal, with date, in the MiSACWIS Appointment screen, Appointment Details. The ADA Principles of Ethics and Code of Professional Conduct. Tags. This page contains information needed to enroll and submit dental claims to the Michigan Department of Health and Human Services (MDHHS) Your refusal to sign will not affect your ability to obtain treatment, payment, enrollment or your eligibility for benefits. An act to provide for the incorporation, supervision, and regulation of nonprofit dental care corporations. This is called Prior Authorization (PA). Your dentist needs to fill out a Prior Authorization Request Form and send it to us if you need care that requires PA.