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.


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)

As of March 18, 2020, Michalkow Orthodontics, PLLC will use Tele-dentistry (video) to assist with communicating with patients and parents. Two way texting, ZOOM, Face-Time, Skype, Facebook Messenger. ( Initials)

I hereby request and give my permission to Dr. Michalkow to release orthodontic records (x-rays, models, photos) and copies of all dental records. I agree to pay the cost of duplicating any records (should I transfer to another office for treatment). A photocopy of this release will be as effective and valid as the original. ( 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)