Treatment/Consent Forms (Patient Consent & Insurance)

Patient Consent Form

If any area of the form is not applicable to you put NA in box.
By signing this consent form, you agree to provide all dental and medical information as accurately as possible and to provide timely updates at regular check-up intervals as requested. You permit the dental professionals associated with this program to perform necessary diagnostic procedures including examination and radiographs (x-rays). You also agree to treatment such as dental prophylaxis (cleaning), simple procedures such as routine fillings and periodontal scaling/cleanings to be performed. You also understand that additional treatment may be necessary for dental and overall health such as extractions, dentures, etc. You understand that these more extensive treatment plans will be presented to the patient or patient’s guardian/power of attorney following the initial exam and cleaning. Any more complicated treatment, such as dental extractions, that traditionally require special post-operative care needs, will require an additional consent form be signed prior to any such treatment being performed.

I understand that the dental provider, Healthy Smiles Forever may use my health information for treatment, payment and health care operations.

I have read and understand the services that may be provided to me by this dental program and I consent to participate.

I understand that I may continue to obtain dental care through any other provider.

I authorize the dental provider to consult with my medical provider(s) as may be appropriate to my health and the provision of dental care. If applicable, I authorize the dental program to provide a written summary of the examination and services provided to the official designee of my long term care facility or residential facility.
If I have dental insurance, I authorize my insurance carrier to be billed for any services provided.*

MedicaidPrivate InsuranceNo Insurance
Please thoroughly complete the following Insurance Intake Form attached - if applicable. I understand that this treatment may affect my future rights and benefits under my dental insurance.

If I do not have dental insurance, I will pay the Dental Provider for all dental services that are charged to me.
If you DO NOT HAVE ANY FORM OF DENTAL INSURANCE, & would like to see if you are eligible for a Sliding Fee Scale, Initial here:
HIPPA information on back read and detailed information was made available and I agree to the terms stated.*
Patient Name:*

First NameLast Name
Guardian Name:*

First NameLast Name
Contact Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Signature*
HIPPA Acknowledment
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Healthy Smiles Forever to use and disclose my protected health information to carry out:*

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)Obtaining payment from third party payers (e.g.my insurance company)
You have the right to review and secure a more detailed copy of our NOTICE OF PRIVACY PRACTICES, which contains a more complete description of uses and disclosures of protected health information and rights under HIPAA. The detailed document is available on our website and at each clinic.

I understand that Healthy Smiles Forever reserves the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that HSF is not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time.
By initialing in the box on this Consent Form, I understand the above information and agree with its content.*
HSF SILVER DIAMINE FLUORIDE (SDF) CONSENT
BENEFITS OF RECEIVING SDF: SDF is an antibacterial liquid. SDF can help stop tooth decay, or slow down decay progression. SDF can help relieve sensitivity.SDF can be a beneficial treatment option for geriatric dental patients, particularly those with limited access to traditional dental care or who have difficulty with complex procedures. SDF offers a non-invasive way to manage dental decay and arrest caries lesions without the need for drilling or fillings. Treatment with SDF does not eliminate the need for dental fillings in all situations. It is most effective when applied 2-3 times per year.Dental decay will stain black permanently. Healthy tooth structure will not stain.I should not be treated with SDF if I am allergic to silver. I hereby acknowledge that I have read this SDF consent agreement (or it was read to me), and I consent to Silver Diamine Fluoride treatment. I understand this consent and the meaning of its content, including the benefits and risks of SDF treatment. I agree to the fees associated with this dental treatment and give informed consent and commit to pay for services rendered, including any charges not covered by dental insurance. All questions have been answered in a satisfactory manner.*

Yes, I approve treatmentNo, I do not approve treatment
By initialing in the box on this Consent Form, I understand the above SDF information and agree with its content.*
HSF INSURANCE INTAKE FORM

Thoroughly complete the following form if you have dental insurance.
NOTE: HSF IS NOT CONTRACTED WITH MEDICARE & HSF DOES NOT BILL MEDICARE AT THIS TIME.

*WE ARE CONTRACTED WITH ALASKA MEDICAID.
Patient's Name:*

First NameMiddle NameLast Name
Patient's Birthdate:*

MonthDayYear
Date
Social Security Number:*
Does this patient have Dental Insurance?*

YESNO
Does this patient have Alaska Medicaid?*

YESNO
Does this patient have more than 1 dental insurance policy?*

YESNO
Primary Dental Insurance
Name of Primary Insurance Company:*
Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber’s FULL Name:*

First NameLast Name
Relationship to Patient:*
Subscriber’s Social Security Number:*
Subscriber’s Birthdate:*

MonthDayYear
Date
Member ID Number:*
Group Number:*
AK Medicaid Member Number (if applicable):*
Insurance Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of employer offering this insurance plan:*
Secondary Dental Insurance
Name of Insurance Company:
Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber’s FULL Name:

First NameLast Name
Relationship to Patient:
Subscriber’s Social Security Number:
Subscriber’s Birthdate:

MonthDayYear
Date
Member ID Number:
Group Number:
AK Medicaid Member Number (if applicable):
Insurance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of employer offering this insurance plan:
Healthy Smiles Forever (HSF) will make every effort to provide the best care for your loved one. Please complete this form in its entirety. HSF is a non-profit organization. Collecting fees is essential to maintaining our program for the residents who so desperately need access to our care. Thank you.
Signature:*
Date:*

MonthDayYear
Date
Email Address:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Print Name:*

First NameLast Name
PLEASE PROVIDE A COPY OF YOUR DENTAL INSURANCE CARD(s)
PRIMARY INSURANCE | Front of Insurance Card:
PRIMARY INSURANCE |Back of Insurance Card:
SECONDARY INSURANCE | Front of Insurance Card:
SECONDARY INSURANCE |Back of Insurance Card:
Should be Empty:

Patient Consent Form

HIPPA Acknowledment

HSF SILVER DIAMINE FLUORIDE (SDF) CONSENT

HSF INSURANCE INTAKE FORM

Primary Dental Insurance

Secondary Dental Insurance

PLEASE PROVIDE A COPY OF YOUR DENTAL INSURANCE CARD(s)