1 Patient Information
2 Dental Insurance
  • Phone Numbers
  • :
  • IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
1 Dental History
2 Health History
  • Place a mark on "Yes" or "No" to indicate if you have had any of the following:
  • HIPAA Information and Consent Form

  • The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov We adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
  • Name
  • date
  • do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM any subsequent changes in the office policy. I understand that this consent shall remain in force from this time forward.
  • Our Dental office would like to “welcome you”! We will take the utmost care and concern for your dental needs. We have a state of the art office with a caring staff. You are very important to us and we would like to make you a part of our dental family. Please see our office policies below: Payment's Our office will always give you a treatment plan for any of your dental needs. We take Cash, and Visa, Master Charge, Discover. Financing We also have our In house financing with “Care Credit” and “Springstone” if your dental needs are beyond the cost of your insurance or if you don't have insurance. Please ask about an application at our reception area. Broken Appointments Also we schedule all appointments for our patient's and to be considerate to others we do require a confirmation call back before all appointments made and if we do not here from you within 48 hrs to confirm we do charge a fee of $25.00 for a broken/canceled appointments. Transfer's of X­rays We also take the state of the art digital x­rays and if the patient transfer's out of our office we do charge $25.00 for the x­rays. I understand the office policies that were presented to me.