Ezra Medical Center’s Mobile Unit is a School Based Dental Program offering the dental services your child deserves right at your child’s school. We provide preventative and restorative care on our Dental Mobile parked directly in front of your school.

Please complete this on-line consent form if you are interested in having your child receive these dental services. We will schedule your child for an initial dental examination at his/her school.

If you have any questions or would like more information, please call us at: 718-686-2091

Dear Parent/Legal Guardian:

Ezra Medical Center’s School Based Dental Program offers a dental program for children. The services are provided inside the Ezra Dental Van, which will be located directly outside your child’s school.

• By completing and signing this form I am giving Ezra Medical Center permission to provide dental services for my child.
• This consent will remain in effect for the entire time my child is a student in the school.
• By completing this form, I confirm that I have been given the opportunity to review Ezra Medical Center’s HIPPA policy and can at any time request to review it again.
• My signature on this form acknowledges that Ezra Medical Center has the right to bill my child’s insurance.
• My signature on this form acknowledges that I have read the patient consent form and received the HIPAA notice of privacy practices and authorization for release of health information to the school.

I consent to the following services:

• Dental Examination and X-rays
• Cleaning, Fluoride Varnish
• Dental Sealants
• Fillings and/or Crowns (for cavities) Local anesthesia, e.g. Lidocaine, may be used for my child.
• Pulpotomies Baby root canal/ nerve treatment, The dentist will contact me prior to performing this procedure.

• Extraction of primary (baby) teeth ONLY, The dentist will contact me prior to performing this procedure.

PLEASE PROVIDE THE NAME OF YOUR CHILD’S INSURANCE AND THE MEMBER ID NUMBER

I hereby authorize Ezra Medical Center to release any information about my child that is needed for proper
reimbursement.

Assignment of Benefits: I hereby authorize payment of benefits directly to Ezra Medical Center or its physician providers for services rendered. No child will be denied services based on his/her insurance status or the inability to pay.

• This authorization may include disclosure of information relating to ALCOHOL, and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV &RELATED INFORMATION only if I place my signature on the appropriate line below. In the event the health information described below includes any of these types of information, and I sign the line on the box below, I specifically authorize release of such information to the person(s) indicated below.

• If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.

• I have the right to revoke this authorization at any time by writing to L’Refuah Medical & Rehabilitation Center (d/b/a Ezra Medical Center) at the address listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

• I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be condition upon my authorization of this disclosure.

• Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal law. Name and address of health provider or entity to release this information: L’Refuah Medical & Rehabilitation Center (d/b/a Ezra Medical Center), 1312 38th Street, Brooklyn, NY 11218. Name and address of Person(s) or category of person to whom this information will be sent: Parent Coordinator Specific information to be released: Information on page 2 and 3 of this form, follow-up evaluation letter Reason for release of information: Required by School

Name and address of health provider or entity to release this information: L’Refuah Medical & Rehabilitation Center (d/b/a/ Ezra Medical Center), 1312 38th Street, Brooklyn, NY 11218.

Name and address of Person(s) or category of person to whom this information will be sent: Parent Coordinator
Reason for release of information: Required by School