Secured Forms

PATIENT REGISTRATION FORM

Patient's Name

Home Phone

Cell Phone

Date of Birth

Name of Spouse

Address

P.O. Box

City

Slate

Zip Code

Social Security No.

Employer

Business Phone

In emergency, please contact

Relationship

Phone

How did you hear about our office?

IF PATIENT IS A CHILD:

Responsible Parent's Name

Address

Phone

Social Security No.

Birth Date

DENTAL INSURANCE INFORMATION

Subscriber Name

S.S. #

Relationship to Patient

Subscriber Date of Birth

Group Number

ID Number

Employer Name

Insurance Company Name

SECONDARY DENTAL INSURANCE

Subscriber Name

S.S. #

Relationship to Patient

Subscriber Date of Birth

Group Number

ID Number

Employer Name

Insurance Company Address

MEDICAL HISTORY

If so, what is the condition being treated?

2. Physician's Name & Address

If so, explain

If so, what medicine are you taking?

Other

If so, explain:

Women

The above Information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. AUTHORIZATION AND RELEASE: I authorize my insurance company to pay benefits to the dentist, and authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges, and if my payments are not received within 30 days of their due date, I agree 10 pay all costs of collections, including, but not limited to, reasonable attorney's fees.

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.

Signature/Print Name

Date

Russell Dental Group, PC

Payment is expected on the day of service. After seeing the Doctor and treatment has been determined, all treatment plans will be discussed, and a financial "estimate" will be given to the patient and/or responsible party. This applies to all patients, with or without dental insurance. We reserve the right to charge interest on an account with a balance over 90 days and a fee on any retumed checks.

Our office files dental insurance as a courtesy. Insurance may have co-pays, deductibles, percentages, and waiting periods for services and not cover all fees at 100%. we will make every effort to file claims with the information provided at the time of services rendered, however, it is the responsibility of the policy holder to know what Insurance covers and what it does not. By signing below, you give Russell Dental Group, PC authorization to file dental insurance that is provided to our office and agree to pay the difference after insurance has paid.

Cancellations

We utilize text messages and phone calls to remind you of your appointment. WE VALUE YOUR TIME, PLEASE VALUE OURS BY GIVING US AT LEAST 24 HOURS NOTICE OF CANCELLATION. After several attempts, if you fail to confirm your appointment, our office reserves the right to cancel the appointment. A $100.00 deposit may be required if there is a history of missed/broken appointments; and we have the right to dismiss a patient from our practice for habitual missed/broken appointments.

Signature/Print Name

Date

Electronic Communication Consent Form

I consent that Russell Dental Group, PC can communicate with me via mobile phone, messages, e-mail, and any other necessary form of online communication, provided that these communications comply with privacy regulations.

APPOINTMENT REMINDERS, RESCHEDULES, CANCELATIONS AND PAYMENTS

I understand that Russell Dental Group, PC can reach me at any time to remind me of my appointment, to discuss any change in an appointment and to attempt to collect payment due on an account. I understand this can be handled directly from the office or by an employed third party.

Signature/Print Name

Date

RUSSELL DENTAL GROUP, PC

NOTICE OF PRIVACY PRACTICES

Effective Date: June 19, 2013

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

CONTACT INFORMATION

For more information about our privacy practices, to discuss Questions or concerns, or to gel additional copies of this notice, please contact our Privacy Officer.

Telephone: (731) 772-2107

Email: russelldental@bellsouth.net

Address: 130 Peachtree Plaza, Brownsville, TN 38012

OUR LEGAL DUTY

We are required by law to protect the privacy of your protected health information ("medical information"). We are also required to send 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 isin effect. This notice takes effect on the date set forth at the top of this page, andwill remain in effect unless we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. Were serve the right to make any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, inducing medical information we created or received before we made the change.

We may amend the terms of this notice at any time. If we make a material change to our policy practices. we will provide to you the revised notice. Any revised notice will be effective for all health information that 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 if applicable. You may request a copy of the current notice at any time.

We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical. electronic and procedural security safe guards 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 or misuse.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

Treatment: We may disclose your medical information, without your prior approval, to another dentist, a physician or other health care provider working 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. For example. your insurance plan may request and receive information on dates that you received services at our facility in order 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 operationsinclude:

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 of plan has or had a relationship with you and the medical information is for that provider's or plan's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud 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 the information, You may take back or "revoke" your written authorization at any time in writing. 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 a 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 any of these communications.

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 only 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 n 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-related products, benefits, services, payment for those products and services, and treatment alternatives.

Reminders: We may use Of disclose medical information to send you reminders about your dental care, such as appointment reminders.

Plan Sponsors: It your dental insurance coverage is through an employer's 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, when required by law, and when authorized by law for the following kinds of public health and public benefit activities:

for public health, including to report disease and vital statistics, child abuse, and 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 with regard to crime victims and criminal activities;
to coroners, medical examiners, funeral directors, and organ procurement organizations;
to the military, to federal officials for lawful intelligence, counter intelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
as authorized by state worker's compensation laws.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to 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 unauthorized acquisition, 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 alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information:

HIV/AIDS;
Mental health;
Genetic tests;
Alcohol and drug abuse;
Sexually transmitted diseases and reproductive health information; and
Child or adult abuse of neglect. including sexual assault.

YOUR RIGHTS

Access: You have the right to examine and to receive a copy of your medical information. with limited exceptions. We will use the format you request unless we cannot practicably do so. You should submit your request in writing to our Privacy Officer.

We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact our Privacy Officer for information about our fees.

Disclosure Accounting: You have the right to a list of instances in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorize by you, and for certain other activities.

You should submit your request to our Privacy Officer. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request.

Amendment: You have the right to request that we amend your medical information. You should submit your request in writing to our Privacy Officer.

We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we deny your request, you may have a statement of your disagreement added to your medical information. If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.

Restriction: You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. Except in limited circumstances, we are not required to agree to your request. But it we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. You should submit your request to our Privacy Officer. Except as otherwise required by law, we must agree to a restriction request if:

except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or heahh care operations (and not for purposes of carrying out treatment), and
the medical information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full by the patient.

Confidential Communication: You have the right to request that we communicate with you about your medical information in confidence by means or to locations that you specify. You should submit your request in writing to our Privacy Officer.

Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Breach may be delayed or not provided if so required by a law enforcement official. You may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if we know the identity and address of such individual(s).

Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact our Privacy Officer to obtain this notice in written form.

COMPLAINTS

If you are concerned that we may have violated your privacy rights. or you disagree with a decision we made about access to your medical information, about amending your medical information, about restricting our use or disclosure of your medical information, or about how we communicate with you about your medical information (Including a breach notice communication), you may contact to our Privacy Officer.

You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for DWI Rights' Hotline at 1-800-388-1019.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I, _________, have received a copy of this office's Notice of Privacy Practices .

Signature/Print Name

Date

Your information will be encrypted.