New Patient Form | Goldsboro Pediatric Dentistry And Orthodontics

HIPAA Information and Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards for your privacy.

A Notice of Privacy Practice should be available to you in the office. The notice provides information about how we may use and disclose protected health information about you in order to carry out treatment, payment and health care operations, and for other purposes permitted or required by law. The notice also contains information about your rights under the law.

Additional information is available from the U.S. Department of Health and Human Services.

By signing below, you understand and agree to the terms of our notice of privacy practices which include:

Protect health information that may be disclosed or used for treatment, payment or health care operations.
Authorization is required for certain disclosures of your protected health information.
You have the right to opt out of receiving fundraising communications.
You have the right to restrict the disclosure of your Protected Health Information under certain circumstances.
You have the right to be notified of a breach of unsecured Protected Health Information.

By signing below, you understand and agree that:

The Practice has a Notice of Privacy Practices that you have the opportunity to review.
The Practice reserves the right to change the Notice of Privacy Practices and if we change our notice, you may obtain a revised copy by contacting our office.
You may revoke this consent in writing at any time and all future disclosures will cease.
The practice may condition the treatment to the execution of this consent.

Patient/Patient’s Responsible Party Signature:

Print Name:

Date:

Consent

All children under 18 must be accompanied by a parent or legal guardian for their appointments. This includes new patient appointments (consults), six-month recall cleaning appointments, restorative appointments, and all orthodontic appointments. It is state law that a parent or legal guardian be present. If your child is brought by any other person they will be asked to reschedule. Further more, due to HIPPA regulations (confidentiality laws), we cannot discuss treatment with anyone other than a parent or legal guardian. Once patient turns 18 years of age we are no longer obligated to discuss treatment or account information with anyone but the patient.

I consent to the disclosure of patient records and or treatment information to the following persons who are involved in the patient's care or payment for that care.

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

My consent to disclosure of records shall be effective until I revoke it in writing.

Authorization and Release of Information

I agree that my dental insurance carrier may be billed for services provided and payment will be made directly to Goldsboro Pediatric Dentistry and Orthodontics. I also assume responsibility for any portion of the treatment cost not covered by my insurance carrier. I hereby give authorization for the release of any information requested or required by my insurance carrier with respect to any insurance claims.

I have read and understand the above.

Patient/Patient’s Responsible Party Signature:

Print Name:

Date:

GPDO: Media Consent

I consent that Goldsboro Pediatric Dentistry and Orthodontics may use photographs or videos of me, taken on the date indicated below, on their social media tools which includes, but not limited to their Facebook page. I understand that these images and/or videos will not be used for any other commercial purposes. Photographs may also be printed and placed for display at our office.

If person(s) in photos/videos is a minor, please list name(s) below:

Patient/Patient’s Responsible Party Signature:

Print Name:

Date:

919-947-0800

300 S Center St Goldsboro, NC 27530

HIPAA Information and Consent

Patient Basic Information

Patient Contact Information

Patient Demographics

Primary Responsible Party Basic Information

Primary Responsible Party Contact Info

Primary Responsible Party Insurance

Additional Information

MEDICAL HISTORY

Medical Conditions

Allergies

Dental History

Previous Physician and Acknowledgement

Consent

Authorization and Release of Information

GPDO: Media Consent