Apt #
Zip Code
If different than home
Apt #
Zip Code


PO Box/Street


PO Box/Street

I certify that the above information is true, to the best of my knowledge. If any of this information changes, I will provide that information to Davis Family Dentistry office as soon as possible. I understand that failure to provide accurate insurance information in a timely manner may result in being billed for the full fee for any services provided to me.



I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payer’s and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist tor dental group insurance benefits for the payment of all services rendered on my behalf or dependants.


Davis Family Dentistry
523 Kirkland Way
Kirkland, WA 98033

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers for my health care services
  • Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below, if necessary:



The Health Insurance Portability & Accountability Act of 1990 (HIPAA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically. on paper. or orally. to be kept confidential. This federal law gives you. the patient, significant new rights to understand and control how your health information ts uscd. HIPAA provides penalties for covered entities that misuse personal health information. As required by law, we have prepared this explanation of how we are required to maintain the privacy of your health intormation and how we may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your bealth care records for the purposes of treatment. payment and health care operations.

  • Treatment means providing, coordinating. or managing health care and related services by one or more health care providers. For example. we may need to share information with other health care providers or specialists involved in the continuation of your case.
  • Payment means such activities as obtaining reimbursement for services. confirming coverage. billing of collection activities. and utilization review. For example, we may disclose treatment information when hilling a dental plan for your dental services
  • Health Care Operations include the business aspects of running our practice. For example. patient information may be used for training purposes,or quality assessment.

Unless you request otherwise, we may use or disclose health information to a family member, friend. personal representative, or other individual to the extent necessary to help with your health care or with payment for your health care. In the event of an emergency or your incapacity, we will use our professional judgment in disclosing only the protected health information necessary to facilitate needed care. In addition. we may use your confidential information to remind you of appointments by sending reminder postcards and/or leaving messages at home and/or work. Your protected health information may also be used by our office to recommend treatment alternatives or to provide you with information about health-related benefits and services that may be of interest to you. In addition, we may disclose your health information for public health oversight activities. judicial or administrative proceedings. in response to a subpoena or court order, to military authorities of Armed Forces personnel, to federal officials for lawful intelligence. counterintelligence, and other national security activities. to correctional institutions or law enforcement officials, and/or to report suspected abuse. neglect. or domestic violence. 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 may exercise by presenting a written request to our privacy_Office 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, with limited exceptions A reasonable fee may be assessed.
  • The right to request an amendment to your protected health information. We may deny Your request in certain situations.
  • The right to receive an accounting of disclosures of protected health information made outside of treatment, payment, or health care operations... or based on your previous authorization.
  • The right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive the notice electronically.

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 information.

This notice is effective as of October 2003, and wears required to abide by the terms of the Notice of Privacy Practices currently in effect, We reserve the night 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, 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 Practices, please contact:

Samira Davis, DDS
523 Kirkland Way
Kirkland, WA 98033
425 822-350

For more information about HIPAA or to file a complaint
The U.S Department of Health & Human Services

Office of Civil Right
200 Independence Avenue. S.W
Washington D.C.20201


APPOINTMENTS POLICY: Please kindly give 48 hours advance notice if you cannot keep your appointment. There is a $50 fee per 60min that will be charged to your account for the time reserved for appointments missed or cancelled late without 48 hours advanced notice given. If you are late to an appointment, please understand that your appointment may be shortened or rescheduled.

PAYMENTS: Payment for the patient’s portion is due at the time of service and to be addressed to Samira Davis, DDS or the DBA: Davis Family Dentistry. Patient portions include estimated patient portions deductibles and co-pays. Insurance estimates are provided as a courtesy, however are in no way a guarantee of coverage. In the event that your insurance carrier pays less than the estimated amount, then you, the patient and/or guarantor, is responsible for the full unpaid balance. Pre-determinations are performed upon request, however are not a guarantee of benefits. We accept cash, check, MasterCard and Visa.

INSURANCE: Insurance is NOT a guarantee of payment. Please remember that your insurance policy is a contract between you, your employer and insurance company. Not all services are covered benefits in all dental contracts. It is your responsibility, as the patient, to review and know your policy, its coverage and limitations, as it is an agreement between you and your insurance company. Our staff will do their best to assist you in coordination of benefits, however it is ultimately your responsibility to keep track of benefits and remaining benefits throughout the benefit year from your insurance. We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.

FINANCE CHARGE: Outstanding balances over 90 days are subject to a 1.5% per month, 18% APR, $1.00 Minimum.

PATIENT AUTHORIZATION: I have read, understand, and agree to the terms and conditions of this financial agreement. I agree to abide by the terms of these financial policy. I authorize this office to release information, relating to my dental care, to my insurance company and authorize payment of benefits to be made to Samira M. Davis, DDS, PS – DBA Davis Family Dentistry. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account. I authorize and give consent for dental treatment of the patient named above and agree to pay all fees and charges for such treatment and services rendered. I understand as the parent and/or legal guardian of the minor receiving dental care at this office, I am ultimately responsible for all payments or fees for dental services rendered to the minor in my care. I agree that this authorization shall remain valid until cancelled by me in writing. FINANCIAL AGREEMENT FOR: Samira M. Davis, DDS, 523 Kirkland Way, Kirkland, WA 98033 425.822.3505