Who is your child's Primary Physician?

We are committed to providing you with the best quality of dental care and excellence in customer service. To achieve these goals, we greatly depend on your cooperation and your understanding of our appointment and payment policies. Thank you for choosing us and for taking time to carefully review the following:

Your appointment time is reserved especially for you. We respect your busy schedule and make every effort to see you on time. Please help us achieve this goal by being punctual for your visit. A minimum of 48 hours notice is required if you are unable to keep your appointment. Repeated cancellations or failure to come to your scheduled appointments may result in a charge and/ or refusal of further care in our office. Thank you in advance for your cooperation.

If your child is uninsured, payment is due at the time of scheduling. We accept cash, personal checks, VISA, MasterCard and American Express. We apply a $25 charge for returned checks.

If your child is insured, as a courtesy to you, we will gladly submit your insurance claims on your behalf. However, we expect and appreciate payment of any deductible and/or estimated charges not covered by your insurance at the time of scheduling. We accept cash, personal checks, VISA, MasterCard, and American Express. If for any reason your insurance does not pay, please be advised that you are responsible for the unpaid charges. This agreement shall not be amended orally. We apply a $25 charge for returned checks.

Our office follows the guidelines of the American Academy of Pediatric Dentistry in regard to frequency of x-rays, cleanings, fluoride treatments, and restorative care. As a specialist we consider these guidelines to be the standard of care (best treatment for your child). These guidelines are not dictated by dental insurance and it is your responsibility to understand whether your particular insurance plan will reimburse you for these services. Please call your insurance company with questions regarding frequencies.

The parent or guardian who is signing this form is responsible for all account transactions and balances.  All outstanding balances shall accrue interest at the rate of 12% per year (interest is compounded). 

If insurance is involved: I authorize payment directly to Dr. Susan Kim, DDS of insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I authorize Evergreen Pediatric Dentistry to use my child's healthcare information in the submissions of all insurance claims in order to obtain payment for services and predeterminations. I authorize all credit inquiries deemed necessary in connection with my account.

Our office is dedicated to prorect the privacy of our patients and the confidential information entrusted to us. It is a requirement of the practice that every employee receive appropriate training and is dedicated to the principal concept that your health information shall never be compromised. We may, from time to time, amend our privacy policies and practices but will always inorm you of any changes that might affect your our obligations and your rights.

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given or disclosed to anyone — even family members — without your consent or written authorization. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality, integrity, and access to your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing or fund-raising purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards unless you direct us otherwise. We will never use, disclose, sell, or otherwise allow access to your personal, protected information in exchange for or receipt of financial remuneration.

Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Breach Notification Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI

You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

IF you'd like a full and complete copy of our Statement of Privacy Practices, please ask at the front desk.

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Evergreen Pediatric Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Evergreen Pediatric Dentistry reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (l understand that the default answer is “NO”. Without indicating “YES” in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)