TREATMENT CONSENT:
Permission for dental services: I authorize Covenant Community Care’s affiliated dentists and/or dental hygienists to provide the following dental services as needed: exam, cleaning, x-rays, fluoride, sealants, and possible additional care such as fillings and extractions. I authorize appropriate lab work to be drawn should a health provider be exposed to a health risk. I acknowledge the receipt of Covenant’s notice of privacy practices. I grant the authority to Covenant Community Care, Inc. the right to take photographs/videos and to copyright, use and publish the same in print and/or electronically with or without your name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising or Web content. By signing this form, I am declaring that my household income is below the amount listed for my family size, and agree to allow Covenant Community Care to bill my insurance
for reimbursement. I understand that if duplicate services are received during follow up care by another provider, insurance benefits may be affected.
I release Detroit Public Schools Community District from any and all claims, losses, damages, injuries, and liabilities and waive all rights in connection with my participation in the "Covenant Community Care Mobile Dental Program." I hereby agree to indemnify and hold harmless the Detroit Public Schools Community District and its respective board members, officers, directors, agents, employees or volunteers from any claims, causes of action, lawsuits or other judicial proceedings, costs, expenses, damages and liabilities, including attorneys’ fees, arising from or related to attendance and, participation in the "Covenant Community Care Mobile Dental Program.
COVID-19 SCREENING:
By signing below, I affirm that on the day of dental treatment, patient has NOT:
- Knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19.
- Tested positive for COVID-19 in the past 14 days.
- Experienced any of the following symptoms of COVID-19 in the past 14 days:
o Fever greater than 100 degrees
o Flu-like symptoms like body aches
o Abnormal cough
o Shortness of breath
o Diarrhea
o Loss of taste or smell
I understand that if I answer yes to any of the above statements on the day of dental treatment, patient will not be able to participate.
NOTICE OF PRIVACY PRACTICES:
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION: We are required to provide thisNotice of Privacy Practices to you by the privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”.) You may request a copy of ourNotice at any time. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all the records of your care generated by thisoffice whether made by your healthcare provider or one of the office’s employees. This office is required by law to: 1. Make sure that health information that identifies you is kept private; 2.Give you this Notice of our legal duties and privacy practices with respect to health information about you; and 3. Follow the terms of the Notice that is currently in effect.
How this OfficeMay Use and Disclose Your Health information:
For Treatment, For Payment, For Healthcare Operations, Appointment Reminders, Treatment Alternatives, Health-Related Benefits andServices, Research, As Required By Law, To Avert a Serious Threat to Health or Safety, Health Oversight Activities, Lawsuits and Disputes, Law Enforcement, and Coroners and MedicalExaminers.
You have the following rights regarding the health information this office maintains about you:
Right to Inspect and Copy, Right to Amend, Right to an Accounting ofDisclosures, Right to Request Restrictions, Right to Request Confidential Communications Right to a Paper Copy of This Notice. You may also obtain a copy of this Notice at our website.
www.covenantcommunitycare.org
.
We reserve the right to revise this Notice. Any revised Notice will be effective for health information we already have about you as well as anyinformation we receive in the future. We will post a copy of any revised Notice in this office.
Complaints:
If you believe your privacy rights have been violated, please contact ourCompliance Officer at 313-228-0220. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. THISOFFICE WILL NOT PENALIZE YOU IN ANY WAY FOR FILING A COMPLAINT.
Other uses and disclosures of your health information not covered by this Notice of Privacy Practices will be madeonly with your written authorization.Omnibus Final Rule Update: Final modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information technologyfor Economic and Clinical Health (HITECH) Act, are as follows: You have the right to be notified of a data breach. You have the right to ask for a copy of your electronic medical record in anelectronic form. You have the right to opt out of fundraising communications from Covenant Community Care, and Covenant Community Care cannot sell your health information withoutyour permission. Certain uses of your medical data, such as use of patient information in marketing, require prior disclosure and your authorization. Use and Disclosure of anypsychotherapy notes require your authorization. Other uses and disclosures not described in this notice will be made only with your authorization. If you pay in cash in full (out of pocket)for your treatment, you can instruct Covenant Community Care not to share information about your treatment with your health plan.
Compliance Officer and Medical RecordsAdministrator: Noah Mamo email:
nmamo@covenantcommunitycare.org
Full notice of privacy practice is posted on our website at
www.covenantcommunitycare.org