We want your dentistry to be a gentle, positive experience. That’s why we strive to provide you with comprehensive, comfortable dentistry. We take all the time necessary to answer your every question and concern. At Downtown Dental, you are more than just a patient or client. Our goal is to serve you as a friend, in a professional, yet caring and comfortable environment.
We offer a variety of services, all designed to give you a beautiful smile and great dental health to last a lifetime. From basic restorative and preventative care, to the latest in cosmetic procedures, we are committed to quality dental care and a positive experience.
Patient’s Name _______________________________________________________ Date ______________
Patient’s Birthday ________________________ _____ Social Security Number ______-______-______
Home Address _________________________________________________________________________________
Home phone__ _____________ Cell Phone _____________ Text notifications from our office OK? __________
Employer _____________________________________________ Occupation _____________________________
The information I have provided is complete and accurate to the best of my knowledge. I consent to whatever procedures are deemed necessary to diagnose my oral condition. I agree to be responsible for payment of all services rendered. I authorize a credit check, should I ask for credit.
Patient Signature _______________________________________________ Today’s Date ________________
MEDICAL DENTAL HISTORY
Date __________________ Physician’s Name __________________________________________________
Patient’s Name ________________________________________________________________________________
Premed Required? Yes No Reason ____________________________________________________
Acknowledgement of Receipt of
Notice Of Privacy Practices
* You may refuse to sign this Acknowledgement *
I, ___________________________________________________, have received a copy of this office’s Notice Of Privacy Practices.
Print Name ________________________________________________________________________________
For Office use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
Acknowledgement could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining the acknowledgement
Other (please specify)
Financial Policy For our Patients
I authorize the Dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such dental care to third party payers and/or health practitioners.
I authorize and herby request my insurance company to pay directly to the dentist, insurance benefits otherwise payable to me.
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents.
I realize that failure to keep this account current may result in this office being unable to provide additional dental services and may require pre-payment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount, or any future outstanding account balances.
Our office wants all of our patients to be able to comfortable afford dental care. We proudly offer the following financial policy so that our patients can have the opportunity to decide which payment option best suits their needs.
Our office will gladly work with you to help get the maximum benefit available to you. Most dental insurance plans do not cover 100% of your cost of treatment. Because of this, you will be asked to pay your deductible and co-payment for charges on the day service is rendered. We will estimate as closely as possible your coverage, but we can make no guarantee of any estimated coverage
. Because your insurance is an agreement between you and your insurance company, the ultimate responsibility for all charges lies with you. If after 60 days the insurance company has not paid on the claim, you will be responsible for the total balance.
1. Cash, Check, or Debit
2. Credit Card – Visa, Mastercard, Discover, and American Express
3. Care Credit – This is a medical credit card with an outside financing company that can be applied for, through our office or website. The application is filled out and within minutes we will know if it is approved or not. They offer interest-free payments for up to 18 months.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 1, 2011, 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. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request.
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.
In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Uses and Disclosures of Health Information
We use and disclose health information about you without authorization for the following purposes.
We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.
We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send claims to your dental health plan containing certain health information.
We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification
, licensing or credentialing activities.
To You Or Your Personal Representative:
We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.
Persons Involved In Care:
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information
, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
We may use or disclose your health information to assist in disaster relief efforts.
Marketing Health-Related Services:
We will not use your health information for marketing communications without your written authorization.
Required by Law:
We may use or disclose your health information when we are required to do so by law.
Public Health and Public Benefit:
We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities
; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers’ compensation or similar programs.
We may disclose health information about a decedent as authorized or required by law.
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
You have the right to look at 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 must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies
, we will charge you $2 for each page, $10 per hour for staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most cases we are not required to agree to these additional restrictions
, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have been paid out of pocket in full.
You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.
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 receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).
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 U.S. 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 Officer: Susan Keith
Address: 123 N Concord Street Knoxville, TN 37919