New Patient Forms

Insurance

In the following questions, check the box if applicable. Your answers are for our records only and will be considered confidential.

Women

To the best of my knowledge, the information provided to this office is complete and accurate. I acknowledge that ALL charges incurred in this office are my responsibility. Should my insurance, for any reason, fail to pay for all the charges billed, I agree to pay for the services upon notification by a representative of this office. I understand that if my account remains unpaid by me for a period of 30 days, it may be referred to an attorney or collection agency for collection and that I further agree to be responsible and pay for all the costs incurred, including up to 33.3% attorney or collection agency fees (minimum of $50.00) and interest at 1.5% per month (18% per annum).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

HIPAA Policy

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care options. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except the extent that you have taken action relying on this consent.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDANDHOWYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOURMEDICALINFORMATION IS IMPORTANT TO US.

CONTACT INFORMATION For more information about our privacy practices, to discuss questions or concerns, or to get additional copiesofthis notice, please contact our Privacy Officer. Telephone: 703-444-4229 21145 Whitfield Place Suite 101 Sterling, VA 20165

OUR LEGAL DUTY

We are required by law to protect the privacy of your protected health information (“medical information”). We are alsorequiredtosend you this notice about our privacy practices, our legal duties and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on thedatesetforth at the top of this page and will remain in effect unless we replace it. We reserve the right, at any time, to changeour privacypractices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve therighttomake any change in our privacy practices, and the new terms of our notice are applicable to all medical information wemaintain, including medical information we created or received before we made the change in practices.

We may amend the terms of this notice at any time. If we make a material change to our policy practices, we will provide it to you,the revised notice. Any revised notice will be effective for all health information we maintain. The effective date of a revised notice will be noted. A copy of the current notice in effect will be available in our facility and on our website. You may request acopyofthecurrent notice at any time. We collect and maintain oral, written and electronic information to administer our business andtoprovide products, services and information of importance to our patients. We maintain physical, electronic and procedural safeguards in the handling and maintenance of our patients’ medical information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction and misuse.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

Treatment: We may disclose your medical information, without your prior approval, to another dentist or healthcare provider working in our facility or otherwise providing you treatment for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed.

Payment: We provide dental services. Your medical information may be used to seek payment from your insurance plan or from you. For example, your insurance plan may request and receive information on dates that you received services at our facility, to allow your employer to verify and process your insurance claim.

Health Care Operations: We may use and disclose your medical information, without your prior approval, for health care operations.Health care operations include:

• healthcare quality assessment and improvement activities;
• reviewing and evaluating dental care provider performance, qualifications, and competence, health care training programs, provider accreditation, certification, licensing, and credentialing activities;
• conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention;and
• business planning, development, management, and general administration, including customer service, complaint resolutions, and billing, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

We may disclose your medical information to another dental or medical provider or to your health plan subject to federal privacy protection laws, as long as the provider or plan has had a relationship with you and the medical information is for that provider’s or health plan’s care quality assessment and improvement activities, competence and qualification evaluation and reviewactivities, orfraud and abuse detection and prevention.

Your Authorization: You (or your legal personal representative) may give us written authorization to use your medical information or to disclose it to anyone for any purpose. Once you give us authorization to release your medical information, we cannot guarantee that the person to whom the information is provided will not disclose that information. You may take back or “revoke” your written authorization at any time, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice. We will obtain your authorization prior to using your medical information for marketing, fundraising purposes or for commercial use. Once authorized, you may opt out of these communications at any time.

Family, Friends, and Others involved in your care or payment for care: We may disclose your medical information to a family member, friend, or any other person you involve in your care or payment for your health care. We will disclose the medical information that is relevant to the person’s involvement. We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts.

We will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated, or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

Health-Related Products and Services: We may use your medical information to communicate with you about health-relatedproducts, benefits, services, payment for those products and services and treatment alternatives.

Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders via US Mail, email, and telephone. By providing your email address to us, you agree that you may receive reminders and breach notifications via email as a possible alternative to US Mail. It is the policy of our office to leave a message on any voicemail or answering machine that may be attached to a number that you provide (home, cell, or work). If you prefer that we do NOT leave a message to confirm treatment or your appointments,

Plan Sponsors: If your dental insurance coverage is through an employer-sponsored group dental plan, we may share summary health information with the plan sponsor.

Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, whenrequiredby law and when authorized by law for the following kinds of public health and public benefit activities;

• for public health, including reporting disease and vital statistics, child abuse, adult abuse, neglect or domestic violence;
• to avert a serious and imminent threat to health or safety;
• for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, and fraud prevention agencies;
• for research;
• in response to court and administrative orders and other lawful process;
• to law enforcement officials regarding crime victims and criminal activities;
• to coroners, medical examiners, funeral directors, and organ procurement organizations;
• to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
• as authorized by state workers’ compensation laws.

Special protection for SUD records: Substance Use Disorder (SUD) Treatment records have enhanced protection. They cannot beused in legal proceedings without your consent or court order.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that applyto us, it is our intent to meet the requirements of the more stringent law.

Business Associates: We may disclose your medical information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Data Breach Notification Purposes: We may use your contact information to provide legally required notices of unauthorizedacquisition, access or disclosure of your health information.

Additional Restrictions on use and disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly Confidential Information” may include confidential information under Federal laws governing reproductive rights, alcohol and drug abuse information, and genetic information as well as state laws that often protect the following types of information:

• 1) HIV/AIDS;
• Mental Health;
• Genetic Tests (in accordance with GINA 2009);
• Alcohol and drug abuse;
• Sexually transmitted diseases and reproductive health information; and
• Child or adult abuse or neglect, including sexual assault.

YOUR RIGHTS

1. You have a right to see and get a copy of your health records.
2. You have a right to amend your health information.
3. You have a right to ask to get an Accounting of Disclosures of when and why your health information was shared for certain purposes.
4. You are entitled to receive a Notice of Privacy Practices that tells you how your health information may be used and shared.

6. You have the right to receive your information in a confidential manner and restrict certain communication methods.

7. You have a right to restrict who receives your information.

8. You have a right to request amendment to be made to your health records by submitting the request in writing to our privacy officer. Your request does not guarantee an amendment, but does guarantee that it will be reviewed and considered.

9. If you believe your rights are being denied or your health information is not being protected, you can:

a. File a complaint with your provider or health insurer

b. File a complaint with the U.S. Government

Office Policy

Our office is committed to meeting and exceeding the standard of dental care. Any charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. As a courtesy to you, we will process your insurance claim from our office for primary and secondary claims only.

Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time services are rendered. Your co-payment may be adjusted after the time of service depending upon the final reconciliation of your insurance payment/explanation of benefits. Please note that any balance remaining after insurance payments is your responsibility and is due to the provider.

Our office accepts Cash, Check, MasterCard, Visa, Discover, American Express, Apple Pay and Care Credit.

Please note that if your account remains unpaid for a period of 30 days, interest at 1.5% will be applied to the debt per month. We send 3 statements to the patient. if the balance remains unpaid, we will refer the debt to the collection agency. If we refer your account to our collection agency (Synergetic Communication, Inc.), you may be subject to additional collection fees (up to 6% interest per year per Virginia Law § 6.2-301).

We require a 48-hour notice for any canceled or rescheduled appointments. Failure to comply with this notice will result in a failed appointment fee (up to $150)

Please do not hesitate to ask if you have any questions regarding this financial agreement or need a copy for your records. We are committed to providing you with the most positive experience in dental care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.