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) requires all health care records and
other individually identifiable health information (protected health information) used or disclosed to us in
any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the
patient, significant new rights to understand and 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.
Without specific written authorization, we are permitted to use and disclose your health care records for
the purposes of treatment, payment and health care operations.
means providing, coordinating, or managing health care and related services by
one or more health care providers. Examples of treatment would include crowns, fillings, teeth
means such activities as obtaining reimbursement for services, confirming coverage,
billing or collection activities, and utilization review. An example of this would be billing your
dental plan for your dental services.
• 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 include a periodic assessment of our
In addition, your confidential information may be used to remind you of an appointment (by phone or
mail) or provide you with information about treatment options or other health-related services including
release of information to friends and family members that are directly involved in your care or who assist
in taking care of you. We will use and disclose your protected when we are required to do so by federal,
state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities
that are authorized by law to collect information, to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a
lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by
another party involved in the dispute, but only if we have made an effort to inform you of the request or
to obtain an order protecting the information the party has requested. We will release your PROTECTED
HEALTH INFORMATION if requested by a law enforcement official for any circumstance required by law.
We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in
order for funeral directors to perform their jobs. We may release PROTECTED HEALTH INFORMATION to
organizations that handle organ, eye or tissue procurement or transplantation, including organ donation
banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent
a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help
prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if you are a member of
U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. We may
disclose your PROTECTED HEALTH INFORMATION to federal officials for intelligence and national security
activities authorized by law. We may disclose PROTECTED HEALTH INFORMATION to federal officials in
order to protect the President, other officials or foreign heads of state, or to conduct investigations. We may disclose your PROTECTED HEALTH INFORMATION to correctional institutions or law enforcement
officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these
purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the
safety and security of the institution, and/or (c) to protect your health and safety or the health and safety
of other individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers'
compensation and similar programs. 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 certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:
• 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 request to receive confidential communications of PROTECTED HEALTH
INFORMATION from us by alternative means or at alternative locations.
• The right to access, inspect and copy your PROTECTED HEALTH INFORMATION.
• The right to request an amendment to your PROTECTED HEALTH INFORMATION.
• The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION
outside of treatment, payment and health care operations. • The right to obtain a paper copy of this notice from us upon request.
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
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. Revisions to our Notice of Privacy
Practices will be posted on the effective date and you may request a written copy of the Revised Notice
from this office. 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, in the event you feel your privacy rights
have been violated. We will not retaliate against you for filing a complaint.
For more information about our Privacy Practices, please contact:
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Reason for Today’s Visit ___________________________________________ Date of last dental care __________________________________
Former Dentist __________________________________________________ Date of last dental X-Rays ________________________________
How did you find out about our office? _______________________________________________________________________________________
Are you satisfied with your smile? Yes No If not, do you want to improve it? Yes No
Check (9) if you have had problems with the following:
How often do you floss? ___________________________________________ How often do you brush? _________________________________
Physician’s Name ________________________________________________ Phone Number ________________________________________
Have you had any serious illnesses or operations? _______________ If yes, describe __________________________________________________
Yes No If yes, give approximate dates_____________________________________________
Are you pregnant? Yes No
Check (9) if you have or have had any of the following:
List medications you are currently taking:
Pharmacy ____________________________ Phone ___________________
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my
minor child, ever have a change in health.
Signature of Patient, Parent, Guardian or Personal Representative
PLEASE PRINT NAME of Patient, Parent, Guardian or Personal Representative Relationship to Patient ________________________________________________________________________ _______________________________________
DENTAL HEALTH HISTORY
NAME ______________________________________________ MARRIED SINGLE MINOR MALE FEMALE LAST
SOCIAL SECURITY # _____________________________
ADDRESS ________________________________________________________________________________________ STREET
TELEPHONE (______)_____________________(______)_____________________(______)_____________________ HOME
E-MAIL ADDRESS _________________________________________________________________________________ (To be used for appointment confirmations and/or office promotions…your e-mail address will NOT be sold)
NAME OF EMPLOYER __________________________________ ADDRESS _________________________________ IF FULL TIME STUDENT, SCHOOL NAME ___________________________________________ GRADE ___________
PERSON RESPONSIBLE FOR ACCOUNT – PLEASE CHECK ONE: PATIENT GUARDIAN SPOUSE FATHER MOTHER
MINOR CHILD – MAY NEED TO COMPLETE BOTH BLOCKS FOR PARENT INFORMATION
DUAL COVERAGE? ALSO COMPLETE SECONDARY INSURED
PRIMARY INSURED / IF NO INSURANCE COMPLETE FOR RESPONSIBLE PARTY
______________________________________________________________________________________________ STREET CITY
______________________________________________________________________________________________ BIRTHDATE (MO/DAY/YEAR)
Has any member of your family ever been treated in our office ?
Whom may we thank for referring you to our office ? ______________________________________________________________________________
PERSON TO CONTACT
IN CASE OF EMERGENCY
NAME _____________________________________________________________________ TELEPHONE __________________________________
METHOD OF PAYMENT
Responsible party currently has an account with this office
I hereby authorize payment directly to the Dental office of the group
insurance benefits otherwise payable to me. I understand that I am
Payment in full at each appointment (cash or personal check)
responsible for all costs of dental treatment. I hereby authorize the Dental
Office to administer such medications and perform such diagnostic,
Card # ________________________________ Exp. Date _________
photographic and therapeutic procedures as may be necessary for proper
I wish to discuss the Dental Office’s Financial Policy
dental care. The information on this page and the dental/medical histories
are correct to the best of my knowledge. I grant the right to the dentist to
If I do not pay the entire new balance within _____ days of the monthly billing
release my dental/medical histories and other information about my dental
date, a service charge will be added to the account for the current monthly
treatment to third party payors and/or other health professionals.
billing period. The service charge will be a periodic rate of ____% per month
(or a minimum charge of $_____ for a balance under $______) which is an
annual percentage rate of _____% applied to the last month’s balance. In the
case of default of payment, I promise to pay any legal interest on the balance
due, together with any collection costs and reasonable attorney fees incurred to
effect collection of this account or future outstanding accounts.
PATIENT INFORMATION (Vers.1)
Patient Consent to receive Mail and/or Telephone Messages
Email Address (please print
) Do we have your permission to:
Send a recall appointment reminder to your home?
Leave appointment, billing or dental information on your answering machine/voice mail/e-mail:
I give permission to share appointment, billing or dental information with the person named below: Name: _________________________________________________ ________________________________________________ ________________ Signature of Patient / Parent or Legal Guardian
Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices with an effective date of April 14, 2003. ________________________________________________ ________________ Signature of Patient / Parent or Legal Guardian
Please note that as of June 1, 2005.
Some changes have been made to our Financial Policy.
All payments are due at the time services are started
unless arrangements are made prior to treatment.
Insurance balances are ultimately the patient’s obligation.
We file (most) insurances at no cost to you as a courtesy.
We are glad to offer this service. However, insurance balances
that are not paid after 60 days may be billed directly to you.
Please keep your walk out statements and follow up
with your insurance to ensure payment is in process.
Patient balances that go unpaid for 30 days or more may
incur the following additional charges:
Interest charges (1.5% per month or 18% APR),
collection fees (up to 42% of the full balance),
and/or legal charges.
Major services require a deposit of at least half the
estimated patient portion at the time the appointment is made.
Appointments not cancelled with 48 hour notice,
may result in charges for time reserved.
A fee of $30.00 will be assessed for NSF checks.
Signature of patient/guardian
Informed Consent Form for General Dental Procedures
You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should
carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no
treatment. Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your dentist and all of your questions are
answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the
probability of occurrence. As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the
success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these
complications are rare, they can and do occur occasionally. Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:
1.) Pain, swelling, and discomfort after treatment;
8.) Allergic reaction to anesthetic or medication;
2.) Possible injury to the jaw joint and related
9.) A root tip, bone fragment or a piece of a dental
structures requiring follow-up care and treatment,
instrument may be left in your body, and may
have to be removed at a later point in time;
3.) Temporary, or, on rare occasion, permanent
10.) If upper teeth are treated, there is a chance of a
numbness, pain, tingling or altered sensation of
sinus infection or opening between the mouth
the lip, face, chin, gums and tongue along with
and sinus cavity resulting in infection or the need
4.) Damage to adjacent teeth, restorations or gums;
11.) Infection in need of medication, follow-up
5.) An altered bite in need of adjustment;
12.) The need for replacement of restorations,
implants or other appliances in the future;
6.) Possible deterioration of your condition which
13.) Need for follow-up care and treatment, including
It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow
your dentist’s advise and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and
return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.
Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise
your dentist immediately so he/she can consult with your physician if necessary.
The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.
If you are a woman on birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult
with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics. This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have
read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications or recommended
treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
Signature of parent (if a Minor) or Legal Guardian
Information Regarding Bisphosphonates
Bisphosphonates are a class of drugs that are used to treat osteoporosis in women. Stronger forms of bisphosphonates are sometimes used in the treatment of certain cancers, as well as for a disorder called Paget’s disease. A connection has been made between bisphosphonate type drugs and a serious bone disease called Osteonecrosis of the Jaw. The United States Food and Drug Association, along with the manufacturer of one of these drugs (Fosamax) issued a warning to health care professionals on this issue on September 24th, 2004. It is very important for you to let us know if you are now, or have ever taken in the past, ANY type of bisphosphonate class drug. If we treat you without knowing if you are now taking, or have taken in the past, any of these drugs, your health could be seriously affected. These drugs continue to affect the body for years after they are no longer being taken, so we must know if you have ever taken any of them. Brand names of these drugs include (but may not be limited to) are:
Are you now, or have you in the past, taken a bisphosphonate drug, including any of the brands
YES __________ NO __________ DATE __________________________
Information on the Election of Treatment Options
Your dentist will design a treatment plan in which he/she will recommend that you undergo specific dental procedures. You will be
presented with the optimum treatment for your particular dental needs. If, in the dentist’s judgment, other acceptable treatment options
exist, these will be discussed with you as well. There are likely to be increased risks and potential complications should you elect to
have an alternative form of treatment that differs from the optimum treatment plan presented to you. Please discuss these issues in
more detail with your dentist. Be sure to understand the potential risks and complications before consenting to treatment. _________________________________________ _______________________________________________________
Signature of parent (if a Minor) or Legal Guardian
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