New Patient Forms

OFFICE POLICIES

We are pleased to welcome you to our practice! In order to serve your child’s/children's needs without any misunderstanding, please find here our office policies. If you have any questions, please do not hesitate to ask.

• PAYMENT INFORMATION. Our practice is considered a fee-for-service practice. Therefore payment is due at the time services are rendered. We accept cash and credit cards (VISA, Mastercard, American Express, Discover, ATM Bank cards and Flex Spending cards). Sorry, NO personal checks. For your convenience, we will place your credit card on file in a secure manner.
  As a courtesy to our patients, we will electronically submit all dental insurance claims so they can easily be processed. Our dental practice does not render services on the assumption that the resulting charges will be covered by insurance. Please understand that the parent/guardian bringing the child to our practice is legally responsible for payment of services rendered, regardless of whether or not they carry dental insurance.
• FINANCIAL RESPONSIBILITY. The parent or guardian who brings the child for the initial visit is considered the responsible party. This parent is required to pay for services rendered regardless of what a divorce/separation decree may state.
• DENTAL INSURANCE. As a courtesy to our patients, although we do not participate with any insurance plans, we do take most PPO insurance plans with out-of-network provider benefits as initial payment.
  Parent and/or Guardian understands that they will then be responsible for any co-pays or deductibles and that our dental practice cannot render services based on the assumption that the resulting charges will be covered by insurance.
  Our office can assist you in verifying that your plan has out-of-network benefits, however our dental practice cannot provide guarantee of payment or exact coverage amounts or manage any frequency limitations and plan maximums. If you have any questions regarding your plan benefits, we strongly encourage you to contact your insurance carrier directly.
• CANCELLATION POLICY. When you make an appointment with our office, we set aside that time and make preparations specifically for your child. Kindly give at least 48 hours notice if you need to rearrange a scheduled appointment. A fee of $100 will be applied for missed appointments and/or appointments cancelled with less than 48 hours notice.

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.

PATIENT & FAMILY INFORMATION

PICTURE

CONTACT INFORMATION

ADDRESS WHERE CHILD RESIDES

FAMILY INFORMATION

SCHOOL INFORMATION

Parent/Guardian 1

Parent/Guardian 2

Dental Insurance (please input the policy holder’s information)

SECONDARY INSURANCE (If applicable)

MEDICAL HISTORY

Please check each box for any health conditions your child has

Allergy history

Please check each box for any health conditions your child has

Dental History

Past Dental Care: (If applicable)

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.

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 DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant rights to control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes:

• Treatment, payment and health care operations.
• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include treatment for pain or injury to your teeth.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identifiable health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may also use or disclose your personally-identifiable health information:

• To your family and friends: We must disclose your information to you. We may also disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment of your healthcare, but only if you agree that we may do so, or if we are presented a valid legal document showing authority of another person to act on your behalf, as, for example, a medical power of attorney or declaration of guardianship.
• To persons involved in your care: We may use or disclose health information to notify, assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care of your general condition. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to use uses or disclosure.
• As required by law: we may use or disclose your health information when we are required to do so by law.
• In case of suspected abuse or neglect: we may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
• For other governmental purposes: we may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to correctional institution or law enforcement official having custody of protected health information of inmate or patient under certain circumstances.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an account of disclosures of protected health information.
• The right to obtain and we have the obligation to provide to you a paper copy of this notice from us at your first service delivery date.
• The right to request a written acknowledgment that you have received a copy of our Notice of Privacy Practices, and an obligation to document our good faith efforts why an acknowledgment was not obtained.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003 OR the date office opened if later than April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil rights, about violation of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services - Office of Civil Rights
200 Independence Ave. S.W. Washington, D.C. 20201 - 202.619.0257
*You May Refuse To Sign This Acknowledgement*

have received a copy of this office’s notice of privacy practices

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.