Child Patient Information Forms

Please correct the errors described below.

YOUR INFORMATION:

PARENT/ GUARDIAN/ RESPONSIBLE PARTY:

DENTAL INSURANCE INFORMATION (PRIMARY INSURANCE)

DENTAL INSURANCE INFORMATION (SECONDARY INSURANCE)

DENTAL HISTORY

MEDICAL HISTORY

ALLERGIES

MEDICATIONS-attach list or note below

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    AUTHORIZATIONS

    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.

    *I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

    *I understand that where appropriate a credit bureau report may be obtained.

    I am responsible for payment of services rendered as well as co-pays, deductibles or other services that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my submissions, whether manual or electronic.

    Acknowledgement of Statement of Privacy Receipt of Practices

    I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Sequim Family Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information, The Statement of Privacy Practices is also posted in the facility.

    Sequim Family Dentistry reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

    ADDITIONAL DISCLOSURE AUTHORIZATION

    ln addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare information to the person(s) identified below. (l understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

    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.

    OFFICE USE ONLY BELOW THIS LINE

    Acknowledgement Not Obtained

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