* PATIENT INFORMATION *

42 S Main St, Muncy PA 17756 | 570-546-3419 | tritownoffice@gmail.com 

* Father (or Husband) *

* Mother (or Wife) *

* Primary Dental Insurance Information* 

* Secondary Dental Insurance Information *

* Authoriztion And Service Charge *

I hereby authorize payment directly to Tri-Town Modern Dental of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or health professionals.

I understand that if I do not pay my entire balance within 25 days of the monthly billing dated an interest charge will be added to my account. The interest charge will be a periodic rate of 1.5% per month which is an annual percentage rate of 18% applied to the last month's balance. In the case of default or payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding balances.

* Dental History *

Please answer the following about your dental history. 

 * MEDICAL HISTORY *

 * Do you now have or have you ever had any of the following? Please explain if you answer yes. *

If you have any of the conditions in bold please call our office prior to your appointment you may need to premedicate.

* To the best of my knowledge, all of the preceding answers on both pages are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. *

Dear Valued Patient, 

We are dedicated to providing you with the best possible treatment and care. As always, we are happy to discuss our services and policies with you. It is important to our professional relationship that you dearly understand our financial policy. Please ask if you have any questions about our fees, policies, or your responsibility.

The following is an overview of our financial policy. We ask that you review this and then sign it, verifying that you have read and understand our policy.

FINANCIAL POLICY

For our patients with dental insurance:

We will continue to aid you by processing your insurance claims to maximize your benefits, and submit to those carriers who remit directly to us. You continue to be responsible for the payment of the estimated portion of your bill at the time of service. Please be aware that we cannot guarantee that the procedures you are having done at any time will be covered by your insurance plan. You will be responsible for additional balance that may be due after the insurance portion has been received by our office. If you have questions about the portion that your insurance will cover, we ask that you contact your insurance carrier or benefit handbook prior to your appointments. Further, we ask that if you are not prepared to pay your balances or co-pays at the time of service that you reschedule your appointment. We accept VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS in addition to cash, checks and debit cards with the VISA and MASTERCARD logo. We will bill your insurance carrier for 60 days for any service. After that time, the balance will be billed to the patient.

When arriving at our office, please notify us if you have had any changes in name, address, phone number, employer, or insurance carrier. With the industry changes due to HIPAA, insurance companies are issuing new employee identification numbers, so please let us know when you receive your new card. It is also very important that we have a social security number on file for every member of your family including children also for HIPAA regulations.

For our patients without dental insurance:

Patients without insurance are responsible for the cost of treatment at the time of service. In addition to cash and checks, we accept VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS. We can process debit cards with the VISA or MASTERCARD symbol on them. We ask that if you are not prepared to pay for your services at the time of treatment that you reschedule your appointment.

When arriving, please notify us of any changes in name, address, phone number, or employer. We do need to have a social security number on file for all members of your family as part of the HIPAA regulations.

For all patients:

Please note that we continue to charge 1.5% monthly (18% APR) on all balances not paid within 30 days. If you are having treatment that is more extensive, and wish to discuss additional payment options, please ask a member of our business staff.

A 24-hour notice is required for cancellation of appointments. Any appointments cancelled with less than 24 hours notice are subject to a $75 missed appointment fee.

Again, if you have any questions about this or any other policies please ask. We are here to help you, and provide you with high quality dental care.

Authorization:

 

I authorize Tri-Town Modern Dental the use and disclosure of my name (first name only), photographic/video images, and/or testimonial for marketing purposes by the practice listed below.  I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.

Purpose:

The photographic/video images, and/or testimonial will be used for: social media and/or advertising.

Revocability:

I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from the date signed.

No Treatment Conditions:

I understand that the practice cannot condition treatment on whether or not I sign this authorization.

 

 

Practice Name: Tri-Town Modern Dental

 

* INFORMED CONSENT LOCAL ANESTHESIA & CHLORHEXIDINE *

I give my consent to Tri-Town Modern Dental to use local anesthetics that the dentist may deem necessary or advisable to enable the providers of service to render dental treatment as indicated on my examination chart, which I acknowledge by my signature below. I also give consent for any dentist or hygienist to irrigate the mouth, when necessary, with the prescriptive rinse Chlorhexidine. Please notify your provider if there is an allergy to Chlorhexidine. When necessary, this rinse is used to help fight against the bacteria which causes periodontal disease. Additionally, any other procedure deemed necessary or advisable as a corollary to the planned treatment for the below named individual.

I understand that occasionally there are complications involved in this type of treatment and/or the use of anesthesia agents: including, but not limited to: numbness, infection, swelling, bleeding, discoloration, nausea, vomiting, allergic reactions, nerve damage, stroke, or cardiac arrest. I further understand and accept that complications may require hospitalization and may even result in death.

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

 

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign. Communications barriers prohibited obtaining the acknowledgement. An emergency prevented us from obtaining acknowledgement. Other (Please Specify)

© 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication, or distribution of this form by any other party requires the prior written approval of the American Dental Association.

NOTICE OF PRIVACY PRACTICES
Tri-Town Modern Dental
Ryan Koch, DDS
Effective Date: January 1, 2026

THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

CONTACT INFORMATION

For more information about our privacy practices, questions or concerns, or to obtain additional copies of this Notice, please contact:

Privacy Officer: Matthew A.Spady, HEM, CHPSE
Telephone: 724-473-0462
Fax: n/a
Email: support@hcspittsburgh.com
Address: P.O. Box 413, Portersville, PA 16051

OUR LEGAL DUTY

We are required by law to maintain the privacy and security of your protected health information ("PHI") in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended, and applicable state law.

We are required to provide you with this Notice explaining our legal duties, privacy practices, and your rights regarding your PHI. We must follow the terms of this Notice while it is in effect.

This Notice applies to all PHI we create, receive, maintain, or transmit, whether oral, written, or electronic. We maintain physical, administrative, and technical safeguards to protect your PHI from loss, misuse, unauthorized access, or disclosure.

We reserve the right to change this Notice and our privacy practices at any time, as permitted by law. Any changes will apply to all PHI we maintain, including information created or received before the change. If we make a material change, a revised Notice will be made available in our office, on our website (if applicable), and upon request. The effective date will be listed at the top of the Notice.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Treatment
We may use and disclose your PHI without your authorization to provide, coordinate, or manage your dental and related health care. This may include sharing information with dentists, specialists, laboratories, pharmacies, or other healthcare providers involved in your care.
Payment
We may use and disclose your PHI to obtain payment for dental services provided, including billing insurance plans, benefit determinations, claims management, and collection activities.

Health Care Operations
We may use and disclose your PHI for health care operations, including:

●        Quality assessment and improvement activities

 

●        Reviewing provider performance, competence, and qualifications

●        Accreditation, licensing, and credentialing activities

●        Audits, compliance reviews, and legal services

●        Fraud and abuse detection and prevention

●        Business planning, management, administration, billing, customer service, and complaint resolution

●        Creating de-identified information or limited data sets for health care operations, public health, and research

We may disclose PHI to another healthcare provider or health plan for their health care operations activities when legally permitted and when there is an existing or prior relationship with you.

YOUR AUTHORIZATION

You or your personal representative may give us written authorization to use or disclose your PHI for purposes not described in this Notice. You may revoke your authorization at any time in writing, except to the extent we have already relied on it. We do not use or disclose PHI for marketing, fundraising, or sale of information without your authorization. You may opt out of authorized communications at any time.

INDIVIDUALS INVOLVED IN YOUR CARE

We may share relevant PHI with family members, friends, or others involved in your care or payment for care, unless you object. We may also disclose limited information to assist with disaster relief or emergency notification efforts when appropriate.

APPOINTMENT REMINDERS & HEALTH COMMUNICATIONS

We may contact you by phone, voicemail, text message, email, or mail to provide appointment reminders, treatment information, and practice-related communications. You may request alternative or confidential communication methods.

PLAN SPONSORS

If your dental benefits are provided through an employer-sponsored plan, we may disclose summary health information to the plan sponsor as permitted by law.

PUBLIC HEALTH, LEGAL, AND SAFETY DISCLOSURES

We may use or disclose your PHI without authorization when required or permitted by law, including for:

●        Public health reporting and vital statistics

●        Reporting abuse, neglect, or domestic violence

●        Health oversight activities

●        Research, when approved by law

●        Judicial and administrative proceedings

●        Law enforcement purposes

●        Coroners, medical examiners, funeral directors, and organ procurement organizations

●        Military, national security, and correctional institution activities

●        Workers’ compensation programs

●        Preventing a serious and imminent threat to health or safety

If another law provides greater privacy protection than HIPAA  we will follow the more stringent law.

SPECIAL PROTECTIONS FOR CERTAIN HEALTH INFORMATION

Substance Use Disorder (SUD) Records
Records related to substance use disorder diagnosis, treatment, or referral are protected by federal law (42 CFR Part 2). These records may not be used or disclosed without your specific written authorization, except as permitted or required by law. Such records are not disclosed for law enforcement, legal proceedings, or administrative actions without a court order or your authorization, except as allowed by law.

 

 

 

Reproductive Health Information
We do not use or disclose reproductive health information for the purpose of investigating or imposing liability related to lawful reproductive health care. Disclosures will only be made as permitted by HIPAA and applicable state law and never for prohibited purposes.

Other Highly Confidential Information
Additional privacy protections may apply to information related to:

●        HIV/AIDS

●        Mental health treatment

●        Genetic testing (GINA)

●        Sexually transmitted infections

●        Child or adult abuse or neglect, including sexual assault

BUSINESS ASSOCIATES

We may disclose PHI to our business associates who perform services on our behalf. Business associates are required by law and contract to safeguard your information and may only use or disclose it as permitted.

BREACH NOTIFICATION

We may use your contact information to notify you of a breach of your unsecured PHI as required by law.

YOUR RIGHTS

You have the right to:

Inspect and obtain a copy of your health records
Request amendments to your health information
Receive an accounting of certain disclosures
Obtain a paper or electronic copy of this Notice
Request restrictions on certain uses or disclosures
Request confidential communication
Choose whether to authorize disclosures for marketing or fundraising
Revoke authorizations at any time (with limited exceptions)
Opt out of fundraising communications
File a complaint without fear of retaliation
To exercise these rights, contact our Privacy Officer.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
Phone: 1-800-368-1019
Website: www.hhs.gov/ocr

We will not retaliate against you for filing a complaint.

This Notice of Privacy Practices is intended to comply with HIPAA, 42 CFR Part 2, and applicable state law as of 2026.

 

* INFECTION CONTROL *

This information is provided to inform you about measures we have taken in our office to reduce the chances of cross- contamination of disease from patient to patient. You will note numerous areas of prevention you may not have seen before. Included among them are:

1.Facemasks: All our clinical personnel wear facemasks during active patient care. These physical barriers assist in reducing the spread of organisms from person to person.

2. Gloves: New nitrile gloves are worn for every patient. These gloves assure you of no contamination from other patients.

3. Disinfection of Counters and Other Surfaces: You may notice a mild chemical odor associated with wiping surfaces. These chemicals are necessary to disinfect surfaces that are touched during patient treatment. Multiple disinfectants are used after every patient.

4. Items Attached to Dental Operating Units: Handpieces, air blowers, suction equipment, etc. are sterilized by a combination of heat and chemicals.

5. Barriers: Plastic, foil, and/or paper is replaced on switches, etc. for each patient.

6. Instruments: All metal instruments placed in your mouth have been sterilized by a combination of heat and chemicals. All plastic items are new for each patient.

7. Air Filtration: The filters in the main HVAC are changed by professionals at least 2 times a year. 

We assure you that every precaution is being taken to avoid any cross-contamination from patient to patient. We welcome your suggestions.

Thank you.