New Patient Information Forms

Patient Information

Parent / Guardian Information

 

Dentist History

Release and Waiver

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

HIPPA NOTICE OF PRIVACY ACT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW CAREFULLY

How we may use and disclose your health information

1. Treatment: We may use and disclose Health Information for your treatment and to provide you with treatment related health care services.

2. Payment: We may use and disclose Health Information so that we or others may bill and receive payment from you, insurance company, or a third party for the treatments and services you received.

3. Health Care Operations: We may use and disclose Health information for health care operation purposes. These uses and disclosures are necessary to mak sure that all our patients receive quality care and to operate and manage our office.

4. Appointment reminders, treatment alternatives, and health related benefits and services: We may use and disclose Health information to remind you of your appointment.

5. Individuals involved in your care or payment of your care: We may share Health Information with a person involved in your medical care or payment for your care. Such as family, your close friends, or guardian.

6. Research: under certain circumstances, we may use and disclose your Health information for research purposes.

SPECIAL SITUATIONS

As Required by Law: we may disclose Health Information as required by international, federal, state, or local law. 

To Avert a Serious Threat to Health or Safety: We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the safety and health of public or another person. 

Business Associates: We may use and disclose Health Information to our business associates who function on our behalf or provide us with services such as billing. 

Organ and Tissue Donation: If you are an organ donor, we may use or release Health Information to an organization that handles organ procurement, banking or transportation.

Military and Veterans: If you are a member of the armed forces, we may release Health Information as required by military command authorities.

Workers' Compensation: We may release health information for workers' compensation or similar programs. 

Public Health Risks: We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report birth and deaths; report child abuse or neglect; report reactions to medication or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or condition; and report to appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. 

Health Oversight Activities: We may disclose Health Information to health oversight agency for activities authorized by law. 

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose Health Information in response to administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 

Law Enforcement: We may release Health Information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and 6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.  National Security and Intelligence Activities: We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 

Protective Services for the President and Others: We may disclose Health Information to authorize federal officials so they may provide protection to the president, other authorized persons or foreign heads of state, or to conduct special investigations.

Inmates or Individuals in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be made if necessary: 1) for the institution to provide you with health care. 2) to protect your health and safety or the health and safety of others, or 3) for the safety and security of the correctional institution.

Your Rights 

You have the following rights regarding Health Information we have about you: 

Right to Inspect and Copy: You have the right to inspect and copy Health Information that may be used to make decision about your care or payment of your care.

This includes medical and billing records. To inspect and copy this Health Information, you must make your request, in writing, to Let’s Smile Dental. 

Right to Amend: If you feel that Health Information, we have is incorrect, or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Let’s Smile Dental.  Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures w made of Health Information for purposes other than treatment, payment, and health care operations for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Yes Braces. 

Right to Request Restrictions: You have the right to request a restriction of limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in you care or the payment for your care, such as a family member or friend. To request a restriction, you must make your request, in writing, to Let’s Smile Dental. We are not required to agree to your request. If we agree, we will comply with you request unless the information is needed to provide you with emergency treatment. 

Right to Request Confidential Communication: You have the right to request that we communicate with you about the medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communication, you must make your request, in writing, to Let’s Smile Dental. Your request must specify how or where you wish to be contacted. We will accommodate reasonable request.

Let's Smile Dental HIPPA Consent Form

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not require that health care providers obtain a consent agreement as it relates to the use and disclosure of individually identifiable health information (IIHI), but many practices will continue to use the Consent Agreement for other purposes. Though it is not necessary to have your consent to allow us to use or disclose your IIHI to others who will treat or you support in providing you quality health care services, it is important to have your consent to use or disclose your IIHI to health care plans to ensure accurate and timely payment for the services rendered. The law requires that we inform you of our policy regarding the protection of your IIHI through our Privacy Notice We may already have a consent agreement from you. Please refer to our Privacy Notice for a full explanation of how this office will protect your individually identifiable health information (IIHI).

The following is a statement that allows us the necessary latitude to work within the new requirements.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 

My signature indicates that i have received a copy or have been asked about receiving a copy of the privacy notice.

FINANCIAL POLICY

 

1. Payment of services rendered is due the day of appointment.

2. Let’s Smile of Fredericksburg assists with filing insurance; however, the Parent/Guardian is directly responsible for payment in full of any and all fees not paid for by the insurance company. When treatment co-pays and fees are quoted by the office, these are estimates only; your actual insurance coverage may be less or more. The insurance company is unable to provide the exact amount that will be paid until the claim is processed.

3. Personal checks that are returned due to insufficient funds are subject to a $60.00 NSF fee.

4. Appointment cancellations with less than 48 hours’ notice are subject to a fee of $60.00 and appointments scheduled for two (2) hours or longer are subject to a $200.00 fee.

5. All accounts over 60 days are considered past due. Such accounts are subject to 1.5% monthly finance charges. Past due accounts may be sent to an authorized collection agency. Accounts sent to a collection agency will be assessed a $50.00 collection charge on the unpaid balance. The Parent/Legal Guardian will also be liable for any applicable attorney fees and court costs. Accounts that have been referred to an outside collection agency will be placed on a CASH ONLY basis for any future treatment.

6. We are required by the State of Virginia to keep patient records for three years past the final date of treatment. If you are moving or leaving the practice for any reason you may request a copy for your records. There may be a minimal charge for the release of your records.

7. I understand that Let’s Smile Dental gives me a financial estimate based on the information the insurance company provided. This estimate is not a guarantee of payment; the insurance company is unable to provide the exact amount that will be paid until they receive the claim.

8. I understand that the fee estimate listed for this dental care is only good for a period of six (6) months from the date of the patient examination.

9. All emergency dental services must be paid for at the time services are performed.

10. Amalgams (silver fillings) are not provided at this office. Most insurance companies do not pay full benefits due to exclusions in individual policies for composite (tooth colored) fillings. The Parent/Legal Guardian is liable for all additional costs.

11. I authorize payment of dental insurance benefits payable to Let’s Smile Dental, unless payable to me directly per the Insurance Plan.

12.  I authorize the release of any information relating to any insurance claims to the relevant insurance company.

 Appointment and Scheduling Policies 

Let’s Smile Dental, strives to provide all of our patients with the most comprehensive and efficient dental care available.  Keeping this in mind, it is very important that parents, guardians and/or patients understand the importance of maintaining their scheduled appointment so that our patients can be seen and scheduled within a timely manner.  When an appointment is broken with less than 24 hours notice or the patient does not show up for their scheduled appointment time with no notice given to the office,  it prevents the practice from being able to fill that time with another patient who is in need of treatment and may even be experiencing pain.  

We do understand that there are times where a patient or family member becomes unexpectedly sick or an emergency prevents the patient/parent/guardian from keeping the appointment.  In this case, we only ask that the patient/parent/guardian contact the office and relay this information to the front desk so that the appointment can be rescheduled accordingly.  Due to an extremely high volume of same day cancellation and/or broken appointments in the past year or more, it has become imperative that the office enforce the following scheduling and appointment policies going forward.  

• Appointments broken with less than 24 hours notice, will result in a broken appointment fee of $60.00 (if applicable to your insurance).
• No Show appointments will also be charged a No Show fee of $60.00 (if applicable to your insurance).
• If a patient/parent/guardian has missed 2 appointments in a 6 month period with less than 24 hour notice or with no notice given, the account will be reviewed and possibly even dismissed from the practice.   
• All appointments that are unconfirmed within 24 hours of the appointment date and time, will be canceled by the practice software and the appointment time will be offered to another patient in need.  Please confirm your appointments via text, email or phone no later than 24 hours prior to the appointment time to avoid cancellation.   

By signing below you are acknowledging that these policies have been outlined to you and the practice reserves the right to enforce the above office policies in an effort to reduce broken appointments and provide our patients with necessary care, within a reasonable timeframe.  

Photo Release Form

 

I hereby grant permission to Let's Smile, PC to use my/my child's photograph and/or video in any marketing, advertising, or teaching materials used to market or advertise the practice, including use on their website and/or social media sites. 

I acknowledge the practice's right to crop or otherwise treat the photograph or video at their discretion. I also acknowledge that the practice may choose not to use my photograph and/or video now but may do so at their discretion later. 

I also understand that once my image is posted on the website, the image can be downloaded by any computer user, which is beyond the control of the practice. I will hold the practice and any affiliated offices harmless from any such use or download.