New Patient Information Form

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WELCOME TO ANNISTON DENTAL GROUP

Thank You for Selecting Our Dental Team

To help us meet all your healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us and we will be happy to help

Patient Information (Confidential)

Payment in full is due at each appointment.

Insurance Information

If Yes, Complete The Following

Patient Medical History

10. Women only:

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Patient Dental History

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Authorization to Release & Discuss Dental Information

The HIPPA privacy law requires that we are only authorized to communicate with patients themselves, guardians, insurance providers and primary care physicians, unless we have authorization in writing by the patient to communicate with others on their behalf. Please provide all family members, spouses or friends you want is to be able to speak with. I give the following named person(s) authorization to take messages or speak with the office of Dr. Karen Connell, DMD, on my behalf regarding (please check all items authorized).

Authorization to Leave Dental Health Information by Alternate Means

With my signature below, I acknowledge and understand that this information will be kept in my medical record and the above parameters will remain in effect until revoked by me in writing. It is my responsibility to notify my healthcare provider(s) should I wish to change one or more contacts listed above.

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NO SHOW / CANCELLATION POLICY

Due to the increased number of patients that do not show up for their scheduled appointments, or cancel/reschedule less than 24 hours in advance, other patients are waiting longer for scheduled appointments. We want to be sure that all our patients can be evaluated and treated as soon as possible, so we ask that you please call our office at 256-236-6021 as soon as possible if you must cancel or reschedule an appointment. You may leave a message on the answering machine if it is after hours. There will be a $25.00 charge for all patients who miss an appointment without giving a 24 hour (one business day) notice. The $25.00 non-cancellation fee must be paid by each individual prior to or on the next appointment date. No exceptions will be made. If you no show for your appointment 3 consecutive times or if you cancel less than 24 hours in advance 5 consecutive times, you will not be allowed to schedule anymore appointments at our office. Contact Information: As a courtesy, our office calls two business days prior to your dental appointments to confirm. It is your responsibility to make sure that Stephanie has your correct and updated contact information. If you have any questions regarding this policy, please contact Denise (Financial Coordinator) or Stephanie (Scheduling Coordinator) at 256-236-6021.

I have read the No Show/Cancellation policy above and understand that if I do not follow this policy I will be charged $25.00 to be paid before my next appointment.

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PAYMENT & TREATMENT CONSENT

Treatment: I hereby give my consent to Anniston Dental Group, L.L.C. for dental treatment, and I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the procedure(s). I understand that during the course of the procedure(s), unforeseen conditions may arise which necessitate procedures different from those contemplated. I, therefore, consent to the performance of additional procedure(s) which the above named Dentist or his/her associates may consider necessary. Insurance: Our professional services are rendered to you, not the insurance company. You should be aware that most insurance pays for only a portion of the cost of dental services. We are happy to help you file the necessary forms so that you receive the benefits to which you are entitled; however, we make no guarantee of any estimated coverage. We cannot be responsible for any changes in coverage. If payment from insurance carrier is not paid within 60 days of treatment day, the patient is responsible for the full amount. In case of default of payment, I promise to pay the balance due, together with any collection costs and attorney’s fees incurred to affect collection of the account. Payment: Payment is due at time of services rendered. Our system is not set up to accommodate payment arrangements.

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Dr. Karen Connell D.M.D. Anniston Dental Group, LLC

1613 Leighton Avenue Anniston, AL 36207

Effective Date of this Notice: September 12th, 2018

Notice of Privacy Practices

As required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In treating you, we will create medical records about you, and will comply with all laws regarding confidentiality of those records. Every member of our staff is trained and informed confidentiality and will follow this notice, including physicians, nursing staff, and office personnel. We will take all precautions to restrict access to confidential records by unauthorized persons.

Ways we may use your IIHI: Treatment. Information is needed to properly evaluate, diagnose and treat you. It is required in order to prescribe medication, order laboratory tests, reschedule you for further treatments, evaluations, and discuss findings with you, your physicians, & caretakers etc., and family if you desire. We will remind you of appointments. Payment. If we file insurance for you, we will provide information to your insurer(s), or to other 3rd parties who may be paying on your behalf, so that we may obtain payment for our services. Statements of any possible outstanding bills will be sent to you, and may contain medical information. Health Care Operations. Our practice may use and disclose your IIHI to operated our business, such as to evaluate quality of care given to you. Other Reasons: Include disclosures required by federal, state or local law: certain special circumstances such as public health risks, health oversight activities, lawsuits, etc. This can include disclosures to medical examiners or coroners, military authorities, police investigations, and the like.

YOUR RIGHTS REGARDING YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)

Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Our practice will accommodate reasonable requests. You do not need to give a reason for your request. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of you IIHI for treatment, payment or health care operations and, to only certain individuals. We are not required to agree to your request. Your request must be in a clear and concise manner to your privacy officer given below. Inspection and Copies. You have the right to inspect and obtain copies of your IIHI that may be used to make decisions about you by submitting your request in writing to the privacy officer. We may charge fees for the costs involved and in certain limited circumstances deny requests. You may request a review of our denial. Amendment. You may request, in writing, an amendment of your health information if you believe it’s incorrect or incomplete, for as long as information is kept by or for our practice. A request MUST provide a reason that supports your request. We will not amend something that, in our opinion, is accurate and complete. Accounting of Disclosures. You have the right to request an “accounting of disclosures”, a list of certain non-routine disclosures our practice might have made of your IIHI for non-treatment or operation purposes. These requests must be in writing & must state a time period, which may not be longer than years from the date of disclosure and may not include dates before April 14, 2003. Multiple requests within a 12-month period will be charged a fee. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of Department of Health and Human Services. To file a complaint with our office, contact the Privacy Officer. You will not be penalized for filing a complaint. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in authorization. Please note we are required to retain records of your care. Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law. Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (email). CHANGES TO THIS NOTICE: We reserve the right to make any changes to this notice, but a current copy will always be posted and available. Any complaints or requests are to be directed to our PRIVACY OFFICERS:

Stephanie Nunn or Denise Walling - - 1613 Leighton Avenue Anniston, AL 36207 (256) 236-6021

I acknowledge, by singing below, that I have read and agree to the Notice of Privacy Practices and Individual Rights

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