Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

Is the Patient Under 18(Minor)?
Yes
No

Guardian Information

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Are You Married?
Yes No
Are You Employed?
Yes No
Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
SIGNATURE
 
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(Your IP Address : )

Responsible Person for the Account( * mandatory to fill )

SELF OTHER

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physicians care now?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Have you ever been hospitalized or had a major operation?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
Do you use controlled substances?
Yes
No
I have answered all the above questions

Medical History

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotheropy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Disease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
I have answered all the above questions

What is the reason for your visit?
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Have you experienced problems associated with any previous dental work?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss ?
Yes
No
Would you like whiter teeth?
Yes
No
Have you ever had scaling and root planing?
Yes
No
Do you brush daily?
Yes
No

Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth ?
Yes
No
Do you still have wisdom teeth?
Yes
No
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are Your Teeth Sensitive to?
Heat
Cold
Other
Previous Dental Practice name?
Last visit to a Dental Office?
Are you happy with the way your smile looks?
Yes
No
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent

COMMUNICATION PREFERENCE FORM

Please indicate which of the following numbers you would like for us to use:*

WHAT IS YOUR PREFERRED COMMUNICATION METHOD?*

Email   Text Message   Phone
In an effort to guard your privacy, please answer the following questions on how best to contact you regarding communication from DENSON DOWNTOWN DENTAL.
In regards to messages left on voicemail or an answering machine, you authorize your doctor or staff
If you wish to allow staff to discuss your protected health information with a person(s) you appoint, please fill out the sections below
DENSON DOWNTOWN DENTAL may share medical, billing, and appointment information with the following individuals:
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Your Information.Your Rights.Our Responsibilities.

Your Rights

You have the right to:

  • Get a copy of your paper or electronic medical record

    You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

    We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

  • Correct your paper or electronic medical record

    You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

    We may say “no” to your request, but we’ll tell you why in writing within 60 days.

  • Request confidential communication

    You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

    We will say “yes” to all reasonable requests.

  • Ask us to limit the information we share

    You can ask us not to use or share certain health information for treatment,payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

    If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

  • Get a list of those with whom we’ve shared your information

    You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

    We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for one within 12 months.

  • Get a copy of this privacy notice

    You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

  • Choose someone to act for you

    If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

    We will make sure the person has this authority and can act for you before we take any action.

  • File a complaint if you believe your privacy rights have been violated

    You can complain if you feel we have violated your rights by contacting us using the information on page1.

    You can file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights by sending a letter to 200 Independence Avenue ,S.W., washington,D.C 20201,calling 1-877-696-6765, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

    We will not retaliate against you for filing a complaint.

Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

    We may contact you for fundraising efforts, but you can tell us not to contact you again.

    • If you are not able to tell us your preference, for example if you are unconscious,we may go ahead and share your information if we believe it is in your best interest.We may also share your information when needed to lessen a serious and imminent threat to health or safety.

    In these cases we never share your information unless you give us written permission:

Our Uses and Disclosures

We may use and share your information as we:

  • Treat you

    We can use your health information and share it with other professionals who are treating you.

    Example: A doctor treating you for an injury asks another doctor about your overall health condition.

  • Run our organization

    We can use and share your health information to run our practice, improve your care, and contact you when necessary.

    Example: We use health information about you to manage your treatment and services.

  • Bill for your services

    We can use and share your health information to bill and get payment from health plans or other entities.

    Example: We give information about you to your health insurance plan so it will pay for your services.

    How else can we use or share your health information? We are allowed or required to share yourinformation in other ways – usually in ways that contribute to the public good, such as public health and research.We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

  • Help with public health and safety issues

    We can share health information about you for certain situations such as:Preventing disease,Helping with product recalls,Reporting adverse reactions to medications,Reporting suspected abuse, neglect, or domestic violence,Preventing or reducing a serious threat to anyone’s health or safety

  • Do research

    We can use or share your information for health research.

  • Comply with the law

    We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

  • Respond to organ and tissue donation requests

    We can share health information about you with organ procurement organizations.

  • Work with a medical examiner or funeral director

    We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

  • Address workers’ compensation, law enforcement,and other government requests

    We can use or share health information about you:For workers’ compensation claims,For law enforcement purposes or with a law enforcement official,With health oversight agencies for activities authorized by law,For special government functions such as military, national security, and presidential protective services

  • Respond to lawsuits and legal actions

    We can share health information about you in response to a court or administrative order,or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you.The new notice will be available upon request, in our office, and on our web site.

Effective date of this policy- 08/01/2016

OFFICE POLICY REGARDING DENTAL INSURANCE

It is your responsibility to provide our office with your insurance information, (company name, identification number, group number, contact information, etc.). In the event of changes with your insurance coverage you will need to inform our office (new coverage, cobra coverage, termination of coverage) as soon as possible.

As a courtesy to our patients with dental insurance, our office may, with your permission, file insurance and accept assignment of benefits. However, regarding dental insurance, you must know:

Your insurance policy is a contract between you and your employer; we are NOT a participating/contracted provider to that contract, our relationship is with YOU, not the insurance company. Your treatment is individually tailored, and not based on your dental insurance benefits or lack of benefits.

We will estimate for you the portion of your total fee which we anticipate your insurance will pay. The remaining, or estimated patient portion is due in full on the date of service. This estimate is based on the information provided to our office from you, your insurance provider and our previous experience with your policy. There may, however be a difference in our best estimate and what your insurance company actually pays. Our estimate of the insurance portion may not reflect year to date maximum allowances and/or deductibles or dental treatment done in other offices.

Dental claims will be filed immediately from our office and benefits are expected to be paid in thirty (30) days. If the claim is not paid by your insurance carrier in forty five (45) days, the unpaid portion will automatically become “self-pay” and a statement will be issued for the unpaid portion. Regardless of what your insurance company pays, or does not pay, you are responsible for the total fee for treatment/services. Account balances that are not paid in full with fifteen (15 days) of the final statement will begin to accumulate finance charges at the rate of 1.5% per month (with a $3.00 minimum).

I understand and accept the financial/dental insurance policies listed above and have had any and all questions answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid any additional fees.

I hereby authorize my insurance benefits to be paid directly to Dr. Jill Denson. I realize that I am responsible to pay for any deductible amount(s), my estimated portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.

SIGNATURE
 
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Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of 50$.

SIGNATURE
 
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(Your IP Address : )
Thank you for visiting DENSON DOWNTOWN DENTAL. We want your visit to be pleasant and comfortable.Please help us by completing this form
Patient Information

Personal Details

Title: First Name: Last Name: Date Of Birth: Social Security Number: Gender: Marital Status:
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name: Last Name: Date Of Birth: Phone Number: Relation to Patient:

Address

Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Email Address: Driver's License:

Emergency Contact Information

Name: Relation: Home Phone: Work Phone: Address: City: State: Zip Code:

Professional Information

Employer Name: Position: Employer Address: City: State: Zip Code:
Are You Employed? Yes No

Spouse Information

Spouse Name: Date Of Birth Phone Number: Employer:
Are You Married? Yes No

Primary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name: Phone Number: Group (Plan , Local , Policy): Insurance Co.Address: City: State: Zip Code: Insured Name: Insured Social Security: Insured Birth Date: Relation: Insured Employer: Employer's Address: City: State: Zip Code:
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name: Phone Number: Group (Plan , Local , Policy): Insurance Co.Address: City: State: Zip Code: Insured Name: Insured Social Security: Insured Birth Date: Relation: Relation: Insured Employer: Employer's Address: City: State: Zip Code:
Do You have Secondary Insurance? Yes No

Responsible Person for Account

Name: Relation Home Phone: Social Security number: Address: City: State: Zip: Employer: Work Phone: Billing Address: City: State: Zip:
Medical History
Are you under a physicians care now?
Yes
No
Details:
Have you ever had a serious head or neck injury?
Yes
No
Details:
Are you taking any medication, pills or drugs?
Yes
No
Details:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Details:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Details:
Have you ever been hospitalized or had a major operation?
Yes
No
Details:
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Nursing Taking oral contraceptives None
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Sulfa drugs Local anesthetics
Others
Details:
Do you use controlled substances?
Yes
No
Details:
Do you or Have you experienced the following ?
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotheropy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmer Heart Trouble / Disease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Value prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Venereal Disease Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
Details:
Dental History
Purpose Of Visit
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Details:
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss?
Yes
No
Details:
Would you like whiter teeth?
Yes
No
Have you ever had scaling and root planing?
Yes
No
Do you brush daily?
Yes
No
Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth?
Yes
No
Do you still have wisdom teeth?
Yes
No
Details:
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are your teeth sensitive to?
Heat
Cold
Other
Current/Previous Dental: Last visit:
Are you happy with the way your smile looks?
Yes
No
Details:
The information on this page is correct to the best of my knowledge.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
Acknowledgedate: Legal Representative: Description of Authority: Your comments regarding Acknowledgements or Consents:
First Name Only Proper Sur Name Other
Name: Relationship: Name: Relationship:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent

COMMUNICATION PREFERENCE FORM

Home Phone: Cell Phone: Work Phone: E-mail:

WHAT IS YOUR PREFERRED COMMUNICATION METHOD?

Email
Text Message
Phone
Email Address(if applicable)
Cell Phone(if applicable)

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for DENSON DOWNTOWN DENTAL in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for DENSON DOWNTOWN DENTAL in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

In an effort to guard your privacy, please answer the following questions on how best to contact you regarding communication from DENSON DOWNTOWN DENTAL.

In regards to messages left on voicemail or an answering machine, you authorize your doctor or staff

To leave messages regarding your medical condition(s), as well as appointment reminders, billing/financial questions, and requests to call the office. To leave only messages regarding appointment reminders and requests to call the office. Do not reference your medical condition(s) in the message.
If you wish to allow staff to discuss your protected health information with a person(s) you appoint, please fill out the sections below

DENSON DOWNTOWN DENTAL may share medical, billing, and appointment information with the following individuals:

Spouse or significant other: Son(s) or daughter(s): Other:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE

The information on this page is correct to the best of my knowledge.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Your Information.Your Rights.Our Responsibilities.

Your Rights

You have the right to:

  • Get a copy of your paper or electronic medical record

    You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

    We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

  • Correct your paper or electronic medical record

    You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

    We may say “no” to your request, but we’ll tell you why in writing within 60 days.

  • Request confidential communication

    You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

    We will say “yes” to all reasonable requests.

  • Ask us to limit the information we share

    You can ask us not to use or share certain health information for treatment,payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

    If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

  • Get a list of those with whom we’ve shared your information

    You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

    We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for one within 12 months.

  • Get a copy of this privacy notice

    You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

  • Choose someone to act for you

    If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

    We will make sure the person has this authority and can act for you before we take any action.

  • File a complaint if you believe your privacy rights have been violated

    You can complain if you feel we have violated your rights by contacting us using the information on page1.

    You can file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights by sending a letter to 200 Independence Avenue ,S.W., washington,D.C 20201,calling 1-877-696-6765, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

    We will not retaliate against you for filing a complaint.

Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

    We may contact you for fundraising efforts, but you can tell us not to contact you again.

    • If you are not able to tell us your preference, for example if you are unconscious,we may go ahead and share your information if we believe it is in your best interest.We may also share your information when needed to lessen a serious and imminent threat to health or safety.

    In these cases we never share your information unless you give us written permission:

Our Uses and Disclosures

We may use and share your information as we:

  • Treat you

    We can use your health information and share it with other professionals who are treating you.

    Example: A doctor treating you for an injury asks another doctor about your overall health condition.

  • Run our organization

    We can use and share your health information to run our practice, improve your care, and contact you when necessary.

    Example: We use health information about you to manage your treatment and services.

  • Bill for your services

    We can use and share your health information to bill and get payment from health plans or other entities.

    Example: We give information about you to your health insurance plan so it will pay for your services.

    How else can we use or share your health information? We are allowed or required to share yourinformation in other ways – usually in ways that contribute to the public good, such as public health and research.We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

  • Help with public health and safety issues

    We can share health information about you for certain situations such as:Preventing disease,Helping with product recalls,Reporting adverse reactions to medications,Reporting suspected abuse, neglect, or domestic violence,Preventing or reducing a serious threat to anyone’s health or safety

  • Do research

    We can use or share your information for health research.

  • Comply with the law

    We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

  • Respond to organ and tissue donation requests

    We can share health information about you with organ procurement organizations.

  • Work with a medical examiner or funeral director

    We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

  • Address workers’ compensation, law enforcement,and other government requests

    We can use or share health information about you:For workers’ compensation claims,For law enforcement purposes or with a law enforcement official,With health oversight agencies for activities authorized by law,For special government functions such as military, national security, and presidential protective services

  • Respond to lawsuits and legal actions

    We can share health information about you in response to a court or administrative order,or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you.The new notice will be available upon request, in our office, and on our web site.

Effective date of this policy- 08/01/2016

OFFICE POLICY REGARDING DENTAL INSURANCE

It is your responsibility to provide our office with your insurance information, (company name, identification number, group number, contact information, etc.). In the event of changes with your insurance coverage you will need to inform our office (new coverage, cobra coverage, termination of coverage) as soon as possible.

As a courtesy to our patients with dental insurance, our office may, with your permission, file insurance and accept assignment of benefits. However, regarding dental insurance, you must know:

Your insurance policy is a contract between you and your employer; we are NOT a participating/contracted provider to that contract, our relationship is with YOU, not the insurance company. Your treatment is individually tailored, and not based on your dental insurance benefits or lack of benefits.

We will estimate for you the portion of your total fee which we anticipate your insurance will pay. The remaining, or estimated patient portion is due in full on the date of service. This estimate is based on the information provided to our office from you, your insurance provider and our previous experience with your policy. There may, however be a difference in our best estimate and what your insurance company actually pays. Our estimate of the insurance portion may not reflect year to date maximum allowances and/or deductibles or dental treatment done in other offices.

Dental claims will be filed immediately from our office and benefits are expected to be paid in thirty (30) days. If the claim is not paid by your insurance carrier in forty five (45) days, the unpaid portion will automatically become “self-pay” and a statement will be issued for the unpaid portion. Regardless of what your insurance company pays, or does not pay, you are responsible for the total fee for treatment/services. Account balances that are not paid in full with fifteen (15 days) of the final statement will begin to accumulate finance charges at the rate of 1.5% per month (with a $3.00 minimum).

I understand and accept the financial/dental insurance policies listed above and have had any and all questions answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid any additional fees.

I hereby authorize my insurance benefits to be paid directly to Dr. Jill Denson. I realize that I am responsible to pay for any deductible amount(s), my estimated portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.

 
  
 
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Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of $50.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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