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Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.
I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need.
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.
At Anderson Pediatric Dentistry, we are dedicated to serving your children in a timely fashion while making scheduling of appointments as convenient as possible. With a large number of patients in our practice, it is extremely important that appointments are confirmed and that patients arrive on time. By helping us stay on schedule, we can better serve your child as well as other children scheduled on that day.
In the event you will be late to an appointment, we request that you notify our office promptly. Patients that are late may be asked to reschedule. If late, other patients that arrive on time or early will be seen before your child.
We understand that emergencies occur however, our office enforces a strict cancellation / failed appointment policy. In the event something occurs which prohibits you from making your appointment, we politely ask that you give our office 24 hours prior notice so we may have the opportunity to allow another patient the privilege to be seen. Failure to provide our office with 24 hours notice prior to cancellation of an appointment or failure to show up for a scheduled appointment will all be classified as a missed or failed appointment. Three failed and or cancelled appointments without a 24 hour notice will result in loss of future appointment privileges. After 3 missed / cancelled appointments without a 24 hour notice, your child will be considered a WALK IN ONLY patient. WALK IN ONLY patients can be brought in on a Monday or Tuesday morning from 8:00 -10:00AM and 1:00 – 3:00PM and will be seen between scheduled patients. We do not guarantee any treatment to be completed.
Our reminder system has the ability to send you text, phone, and email reminders, and we politely request you provide us with the proper information so we have the best opportunity to contact you to confirm your child’s appointment. It is your responsibility to notify us if you have any changes in your contact information.
I have read and agree with the appointment policy above for Anderson Pediatric Dentistry. I understand that I am responsible for contacting Anderson Pediatric Dentistry in a timely fashion in the event an appointment must be cancelled or rescheduled. I also understand I am responsible for providing Anderson Pediatric Dentistry with updated contact information in a timely fashion.
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.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for healthcare operations are financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
in some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
when a state or federal law mandates that certain health information be reported for a specific purpose;
for public health purposes, such as contagious disease reporting, investigation, or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; uses or disclosures for health-related research;
uses and disclosures to prevent a serious threat to health or safety; uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
disclosures of de-identified information;disclosures relating to worker's compensation programs;disclosures of a "limited data set" for research, public health, or healthcare operations;incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information;
Unless you object, we will also share relevant information about your care with your family or friends who are heiping you with your dental care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation, you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. :
You can ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office
ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using Email to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office.
ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have ta pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office.
ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make.
You May Refuse to sign This Acknowledgement
have received a copy of this office’s Notice of Privacy Practices.
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