New Patient Information Form

I certify that I have read and understand the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

 

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

Payment Agreement

I agree that I am responsible for all services rendered to the Patient that payment is due and payable to the Practice at the time services are rendered and that health, dental, and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if the payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

I understand that the estimated insurance benefit is just that, an estimate, and I am personally
responsible for any balance not paid by insurance. Examples include, but are not limited to:

1. The treatment cost goes over the annual maximum insurance allowance.
2. The insurance company denies any of the treatment.
3. I am not eligible for insurance benefits.
4. I prevent or delay payment by not complying with requests for insurance information, forms, or signatures.
5. I do not complete my treatment and it results in non-payment by the insurance company.
6. Additional lab costs are incurred for any reason, including missed appointments.
7. I received my insurance check and did not sign it over to Complete Dental Studio.
8. I discontinue or am dropped from my insurance plan and this results in non-payment.
9. Insurance fails to pay for any reason.

I hereby authorize payment of my dental insurance benefits directly to Complete Dental Studio. I understand I am financially responsible for any charges not covered by this authorization. I hereby accept the recommended treatment plan and authorize release of any information related to this claim. I have read and understand my obligations with regard to the acceptance of my dental insurance as payment.

Our office strives to bring its patients state-of-the-art technology to provide you with the latest advancements in oral health. We have recently introduced the OralID screening device into our office. The OralID examination will allow us to visualize any oral mucosal abnormalities including cancer and dysplasia (precancer) before they can be detected with the naked eye. The procedure is quick, painless and no rinses or dyes are used.

Similar to other cancers, early detection of Oral Cancer is critical. Studies have shown that early detection of oral cancer with technologies like the OralID dramatically improves the survivability of the disease. If oral cancer is detected in its later stages, which typically occurs during a conventional oral cancer exam, the chance of survival is dramatically reduced.

Who is at Risk?

• Age – 17+ years
• Tobacco Use
• Alcohol Use
• HPV Infection

If you have any questions about risk factors, please feel free to talk to our team. We recommend all our patients be screened with the OralID annually to reduce the mortality of late-stage detection.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review carefully.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 02/01/2026 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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new notice 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. 

How we may use and disclose health information about you. 

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV- related information, genetic information, alcohol and/or substance use disorder treatment records, and mental health records may be entitled to special confidentiality protections under applicable state and federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records. 

Treatment.  We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you. 

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determination of eligibility and coverage to obtain payment from you , an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information. 

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. 

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends, or any other individual identified by you when they participate in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information. 

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts. 

Required by Law. We may use or disclose your health information when we are required to do so by law. 

Public Health Activities. We may disclose your health information for public health activities, including disclosures to: 

• Prevent or control disease, injury or disability;
• Report child abuse or neglect;
• Report reactions to medications or problems with products or devices;
• Notify a person of a recall, repair, or replacement of products or devices;
• Notify a person who may have been exposed to a disease or condition; or
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information and 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.

Security of HHS. We will disclose your health information to the Secretary of the U.S Department of Health and Human Services when required to investigate or determine compliance with HIPAA. 

Worker’s Compensation. We may disclose your PHI to extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law. 

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. 

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system , government programs, and compliance with civil rights laws. 

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting  party or us, to tell you about the request or to obtain an order protecting the information requested. 

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. 

Coroners, Medical Examiners, and Funeral Directors.  We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with  applicable law to enable them to perform their duties. 

Fundraising.  We may contact you to provide you with information about our sponsored activities, including fundraising programs as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications. 

SUD Treatment Information. If we receive or maintain any information about you from a substance use disorder treatment program that is covered by 42 CFR Part2 (a “Part 2 Program”) through a general consent you provide to the Part 2 Program to use and disclose the Part 2 Program record for purposes of treatment, payment or health care operations, we may use and disclose your Part 2 program record of treatment, payment and health care operations purposes as described in this Notice. If we receive or maintain your Part 2 program record through specific consent you provide to us or another third party, we will use and disclose your Part 2 Program record only as expressly permitted by you in your consent as provided to us.

In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order. 

Other Uses and Disclosures of PHI

You authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use of disclosure of PHI for marketing , and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice )or as otherwise permitted  or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already acted in reliance on the authorization. 

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor or copies, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. 

If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law. 

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. 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 the additional requests. 

Rights to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your Written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to the health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full. 

Alternative Communication. 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. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have. 

Amendment. 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. If we agree to your request, we will amend your record(s) and notify you in such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights. 

Right to Notification of a Breach. You will receive notification of breaches of your unsecured protected health information as required by law. 

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Website 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 if 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 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. 

Thank you for filling out your Privacy Notice Form!

Please let us know who is eligible to receive your information on your behalf. These individuals will be the only ones who can receive any information. Example: Appointment Times/Dates, and Treatment information

Preferred Pharmacy Information

Your protected health information (i.e. individually identifiable information such as manes, date, phone/fax number, email, home address, social security numbers and demographic data) may be used or disclosed by used in one or more of the following aspects.

• To other health care providers in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleaning, surgery, etc.)
• To third party payors or spouses (i.e. insurance companies, administrators of flexible spending accounts etc..) to obtain payment of your account
• To certifying, licensing bodies in connection with obtaining certification, licensure of accreditation;
• Internally, to all staff members who have any role in your treatment;
• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
• To your family and close friends involved in your treatment; and/ or,
• We may contact you to provide appointments reminders of information about treatment alternatives or to the health-related benefits and services that may be of interest to you.
• Any other uses of disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke,

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosures of your protected health information;
• Request confidential communication of your protected health information;
• Inspect and obtain copies of your protected health information through asking us;
• Amend or modify your health information in certain circumstances;
• Receive and accounting of certain disclosures made by us of your protected health information;
• You may, file a complaint as to any violation by us of your privacy with us (by submitting inquires to the office manager at our office address) to the US secretary of health and human services (which must be filed within
  180 days of violation)

We have the following duties under the privacy rules:

• By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy with respect to such information;
• To abide to the terms of out privacy notice that is currently in effect;
• To advise you of your rights to change the terms of the privacy notice and to make new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a
  copy of the revised privacy notice.

Please note that we are not obligated to:

• Honor any request by you to restrict the use or disclosure of your protected health information;
• Amend your protected health information if, for example it is accurate and complete
• Provide an atmosphere that is totally free of the possibilities that your protected health information may be incidentally over hear by other patients and third parties.
  This privacy notice is effective as of the date of your signature. if you have any questions about the information
  in the notice, please ask for more information from the manger. Thank you

*Patient acknowledgement

I hereby acknowledge that I have received and reviewed a copy of this privacy notice