Welcome To Our Practice

Please take a few minutes to answer the following questions so we can better assist you with your health care needs.

Responsible party Information

LAST
FIRST
MI

Primary Insurance

Secondary Insurance:

ASSIGNMENT AND RELEASE

I, the undersigned, certify that my dependent(s) have insurance coverage and assign Junior Smiles of Stafford to receive all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Office Policy:

We realize that every person's financial situation is different. For this reason, we strive to make sure to obtain the most accurate coverage information available for each person. However, if for any reason insurance cannot be verified before the time of the appointment, or incorrect coverage is quoted by your insurance company, the responsible party will be responsible for all/difference of all services rendered.

Insurance:

Patients are responsible for co-payment and yearly deductibles. As a courtesy all dental claim forms (if any) will be filled by our office on your behalf. Please note full payment is required at the time of service. Patients are ultimately responsible for any charges that the insurance company does not pay, regardless of any UCR clauses that are in your policy. Please remember that insurance is a contract between the policy holder and the carrier and it is considered one method of payment.

Appointments:

Missed appointments or cancellations may be rescheduled without charge with a 24-hour notice if given Monday-Saturday 9am-5:00 PM and you may leave a voicemail if calling outside of our business hours. All other appointments/cancellations will be charged directly to patient's accounts at $50 per missed appointment. If a patient does not show up or call to cancel (24-hour notice) a Saturday appointment, then no other Saturday appointments will be given to the patient. If an appointment is called to rescheduled three times in a row, it will not be rescheduled, instead the appointment will be placed on a quick fill list, and when the patient's time allows, parent may call to see if the doctor's schedule will allow them to be seen the day they call. All appointments are confirmed 48 hours in advance, please be sure to return all calls, as this is a courtesy service by our office. If an appointment is not confirmed before 24-hour notice, the appointment may be canceled with or without notice and cancellation charge may occur

I CERTIFY THAT I HAVE READ POLICY STATEMENTS ABOVE AND I HAVE UNDERSTOOD ALL OF THE TERMS. I WILL FOLLOW THE PROVISIONS AS ATATED ABOVE.

Child Health/Dental History Form

LAST
FIRST
INITIAL
PO OR MAILING ADDRESS
CITY
STATE
ZIP CODE
Home
Work
If you answer yes to any of the three items above, please stop and return this form to the receptionist.
Has the child had any history of, or conditions related to, any of the following:
Please list the name and phone number of the child's physician:

Child's History

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Acknowledgement of Receipt of Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

Authorization to Release Information

Purpose: This form is used to obtain authorization regarding patient covered under the Privacy Act to people other than yourself.

For office use only

We attempted to obtain written acknowledgement of our receipt of out Notice of Privacy Practices, but acknowledgment could not be obtained because individual refused to sign

Other
For completion by dentist

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our leg al duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 9/23/2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends, or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

Required by Law.We may use or disclose your health information when we are required to do so by law.

Public Health Activities.We may disclose your health information for public health activities, including disclosures to:

  • Prevent or control disease, injury or disability
  • Report child abuse or neglect
  • Report reactions to medications or problems with products or devices
  • Notify a person of a recall, repair, or replacement of products or devices
  • Notify a person who may have been exposed to a disease or condition; or
  • Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national ecurity activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker's Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consist ent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt o f the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you re quest if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting.With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your h ealth information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction.You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication.You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.

Amendment.You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach.You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice.You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).