New Patient Form

Patient Information

Financial Party Information


Insurance



Medical History




Dental History





This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

NOTICE OF PRIVACY PRACTICES








  • As required during an investigation by law enforcement agencies
  • To avert a serious threat to public health or safety
  • As required by military command authorities for their medical records
  • To workers’ compensation or similar programs for processing of claims
  • In response to a legal proceeding
  • To a coroner or medical examiner for identification of a body
  • If an inmate, to the correctional institution or law enforcement official
  • As required by the US Food and Drug Administration (FDA)
  • Other healthcare providers’ treatment activities
  • Other covered entities’ and providers’ payment activities
  • Other covered entities’ healthcare operations activities (to the extent permitted under HIPAA)
  • Uses and disclosures required by law
  • Uses and disclosures in domestic violence or neglect situations
  • Health oversight activities
  • Other public health activities











NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT






ABOUT I-CAT® CBCT CONE BEAM SCANS



Media Release Form