• If you are using non-mechanical contraceptives, antibiotics may interfere with their effectiveness. Consult your physician; you may wish to use mechanical forms of birth control for one full cycle after completion of antibiotic treatment.

1. I understand that the above information is necessary for the doctor to provide me with comprehensive dental care in a safe manner. I have answered all questions truthfully and to the best of my knowledge.
   
   
2. I authorize Dr. Krizman to take radiographs and photographs, make study models, or employ other diagnostic aids deemed appropriate for the purpose of making a thorough diagnosis of my dental needs. Unnecessary radiographs will not be taken.
   
   
3. I authorize Dr. Krizman to perform all recommended treatments with which I have agreed, and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk.
   
   
4. I authorize the release of examination findings, diagnosis, treatment program, etc., to my referring or treating dental specialists and/or physicians.
   
   
5. I understand that all responsibility for payment for dental services provided in this office for myself and/ or for my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made.
   
   
6. I understand that it is my responsibility to advise your office of any changes in the information contained on this form.
   
   
7. If I am 18 years of age or older and if my parents/guardians are my guarantors, I give permission for Dr. Krizman to place a phone call to my parents'/guardians' home regarding account balances and/or account credits and/or to mail statements or other information to my parents'/ guardians' home address regarding account balances, and/or account credits.
   
   
8. Provided that my name is not revealed, Dr. Krizman may use study models, radiographs, and photographs of my mouth in lectures or seminars in which the doctor conducts.

This Notice of privacy practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations, "TPO," and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. "Protected health information," or "PHI," is information about you, including demographic information, that may identify you, and that relates to your past, present, or future physical or mental health condition and related health care services.

General: Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to another physician to whom you have been referred ensure that the physician has the necessary information to diagnose or treat you or to a home health agency that provides care to you or as required.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to dental school students or interns that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you; we may use or disclose your protected health information, as necessary, to contact you of your appointment.

Disclosure Required by Law: We may use or disclose your protected health information in the following situations without your authorization. These situations include, as required by law, matters public health issues, communicable diseases, health oversight, abuse or neglect; Food and Drug Administration requirements; legal proceedings; matters concerning law enforcement, coroners, funeral directors, and organ donation; medical/dental research; criminal activity; military activity and national security; workers' compensation matters; and inmates required uses and disclosures. Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of section 164.500.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Following is a statement of your rights with the respect to your protected health information:

You have the right to Inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following: psychotherapy notes; information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to a law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations.

You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request if your physician believes it is in your best interest to permit use and disclosure of your protected health information; your protected health information will not be restricted. You then have the right to use another Health care Professional.

You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made. if any, of your protected health information.

We reserve the right to change the terms of this of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

You may complain to us or to the secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 5, 2014.

We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by the phone at our main telephone number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

I hereby authorize Jeanne Anne Krizman, DMD, PLC to share my dental records for myself or my dependent with the following people:

EANNE ANNE KRIZMAN, D.M.D., PLC
1601 N Tucson Blvd, Suite #35
Tucson, AZ 85716
P: (520)326-0082/F: (520)447-7810

Thank you for choosing our office for you dental needs. We are committed to provide the highest quality of dental care available to all our patients, and to have those services comfortably affordable, we are pleased to offer you options for payment. The following is a statement of our Financial Policy which must be reviewed and signed.

As a courtesy, our office will provide you with the proper dental codes so that you may submit your insurance claims independently. Our patients generally receive reimbursement from their insurance carriers in 4-6 weeks. We are out-of network providers and therefore have no connection to your insurance plan.

PAYMENT IS DUE WHEN SERVICES ARE BEING RENDERED. Ours is a small office, and we depend on our patients paying the agreed fee when services are rendered. If you cannot pay at the time that service is rendered, you must make alternate arrangements acceptable to us before treatment begins.

We offer the following payment options:|

Cash or Check Payment. Visa, Master Card, American Express, Discover, Debit. No Interest Payment Plan with Care Credit (OAC). If you intend to pay by OAC, you must make arrangements acceptable to us before treatment begins.

A $25.00 returned check fee will be billed for any returned checks.

Thank you for understanding our Financial Policy. We are here to assist you in any way possible. Please make your questions and concerns known to our team, as our goal is to ensure that you have an outstanding experience. I have read the Financial Policy. I understand and agree that:

I understand that my insurance is a contract between me and my insurance company and that Jeanne Anne Krizman DMD, PLC does not file insurance claims for you. I understand that Dr. Krizman is not in network with my insurance, and authorized payment from my insurance will be paid directly to me. I understand that Jeanne Anne Krizman DMD, PLC is a fee-for-service dental-care provider. I understand that insurance is not a guarantee of payment.

Dear Valued Patient,

Our purpose is to help our patients keep their teeth and gums healthy for life. Proper scheduling of appointments is vital to this endeavor. Therefore, we ask for your cooperation regarding the following appointment policy:

• Every effort is made to keep on schedule so we respectfully ask patients to be prompt and keep their appointments. We try to remind patients by telephone prior to their appointment, but please do not depend on this courtesy. If we are unable to reach you, your appointment card will serve as the confirmation of your appointment and implies your obligation and agreement to be present at the appointed time. That time has been reserved especially for you. This means no other patient has been scheduled for that particular time slot and chair, and that anyone else wishing to schedule for that time has had to be given a different time for their appointment. We reserve the right to charge for office visits cancelled or broken with less than 2 business days advance notice (e.g., if your appointment is scheduled for Monday at 3 P.M., and you need to re-schedule, you must call us before the prior Thursday at 3 P.M.). Exceptions to this policy can be determined only on an individual basis, according to the circumstances. The broken appointment charge will depend on the procedure and time reserved, but will start at $50.00 per hour for the hygienist and $125.00 per hour for the doctors.
  
  
• In order to ensure that we keep to our schedule, and yours, as much as possible and to minimize patient waiting time, it is necessary to schedule certain procedures for specific times during the day. This allows us to provide you with the excellence in care that you expect and deserve. We know that your time is valuable and that none of our patients want to spend any longer in the dentist’s office than they have to. Scheduling specified procedures for specific time slots allows us to be more efficient with your treatment and actually minimizes the time you have to spend at our office.

If you have any questions about this policy, do not hesitate to ask our office staff. We believe that good communication is key to providing you with quality dental care.