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RESPONSIBLE PARTY INFORMATION

ORTHODONTIC INSURANCE INFORMATION

Insurance information cannot be verified unless the Group ID# is provided. If the group ID# shown on your insurance card differs from your social security number, we will also need your social security number.

Brian A. Michalkow D.D.S, M.S.

phone  810 629 0470    office  17200 Silver Parkway, Suite 2 Fenton, MI 48430
email  smile@michalkowortho.com    web  www.michalkowortho.com

MEMBER

AMERICAN ASSOCIATION OF ORTHODONTISTS

MEMBER

MICHIGAN DENTAL ASSOCIATION

MEDICAL - DENTAL HISTORY

Brian A. Michalkow D.D.S, M.S.

phone  810 629 0470    office  17200 Silver Parkway, Suite 2 Fenton, MI 48430
email  smile@michalkowortho.com    web  www.michalkowortho.com

MEMBER

AMERICAN ASSOCIATION OF ORTHODONTISTS

MEMBER

MICHIGAN DENTAL ASSOCIATION
Patient Acknowledgement and Consent Form

Effective April 14, 2008, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that the office of Michalkow Orthodontics, PLLC comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future. To comply with one of HIPAA's requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review of entity's functions; a claim for payment of fees; a third party payers examination of our records; a court order as part of a criminal investigation; identification of a deceased; a licensure investigation;or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we make a referral to, or consult with, another dentist or other health care professional, provided a specimen to a laboratory for testing, or otherwise make disclosures of your information in connection with providing, or coordinating, your orthodontic treatment.

As of March 1st 2012, Michalkow Orthodontics, PLLC will submit insurance claims electronically. Initials)

Patient Acknowledgement

Please sign this form below under the heading "acknowledgement" to acknowledge that you have received a copy of our Notice of Privacy Practices.

I acknowledge that I have today read a copy of the Notice of Privacy Practices


(Parent signature if patient under 18 years old)
Patient Consent

Please sign this form below under the heading "Consent" to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.


(Parent signature if patient under 18 years old)

Brian A. Michalkow D.D.S, M.S.

phone  810 629 0470    office  17200 Silver Parkway, Suite 2 Fenton, MI 48430
email  smile@michalkowortho.com    web  www.michalkowortho.com

MEMBER

AMERICAN ASSOCIATION OF ORTHODONTISTS

MEMBER

MICHIGAN DENTAL ASSOCIATION