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Health / Dental History for Child
PATIENT INFORMATION
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RESPONSIBLE PARTY INFORMATION
INSURANCE INFORMATION
EMERGENCY CONTACT INFORMATION
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Dental History
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Medical Information
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I, understand and have completed the health questionnaire and certify that the preceding Infomation is true and correct. This office will not be held responsible for any problem arising out of Inadequate Information not disclosed. I grant authority to the Doctor and Staff to perform all procedures and treatments In the patient’s best Interest I understand that, where appropriate, a Credit Bureau Report may be obtained.

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HIPAA Notice of Privacy Practices

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access To This Information. Please Review It Carefully.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, 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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you at your next visit.

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.

Uses and Disclosures of Protected Health Information

Your health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment

We may use and disclose your health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, a consultation between health care providers relating to a patient or a referral of a patient for health care from one health care provider to another.

Payment

We may use and disclose your health information to others for purposes of processing and receiving payment for treatment and services provided to you.

Healthcare Operations

We may use or disclose, as needed, your health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training, licensing, and conducting or arranging for other business activities. For example, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your health information as necessary, to contact you to remind you of your appointment. We may use or disclose your health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Disease: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Department of Health and Human Services in investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures

Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization

At any time, in writing, except that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Health Information Rights

Following is a statement of your rights with respect to your health information.

Access

You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You may be asked to make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contract information listed at the end of this Notice.

Restriction

You have the right to request that we place additional restrictions on our use or disclosure of your health information. Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your health information, your health information will not be restricted. You then have the right to use another Healthcare Professional.

Alternative Communication

You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

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. You may obtain a form to request an amendment to your health information by using the contact information listed at the end of this Notice.

Disclosure Accounting

You have the right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 7 years, but not for disclosures made prior to April 14, 2003.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Information

Privacy Officer
15029 N. Thompson Peak Pkwy. Suite B-119
Scottsdale, AZ 85260
Phone: (480) 614.2211
Email: info@arcticsmiles.com

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

(Custodial / Responsible Party / Guardian)

(Custodial / Responsible Party / Guardian)