• WELCOME!

  • Sunny Hollow Dental
    Lee J. Weltman, DDS

    Thank you for selecting our dental healthcare team!
    We will strive to provide you with the best possible dental care. To help us meet all your dental needs, please fill out this form completely. If you have any questions or need any assistance, please ask us - we will be happy to help.

  • Patient Information

    (CONFIDENTIAL)
  • Date
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  • Patient's Sex
  • Birthdate
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you prefer to receive calls at your
  • Check Appropriate Box
  • Student Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • RESPONSIBLE PARTY

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate
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  • Format: (000) 000-0000.
  • Is this Person Currently a Patient in our Office?

  • INSURANCE INFORMATION

  • Birthdate
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  • Date Employed
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  • Format: (000) 000-0000.
  • DO YOU HAVE ANY ADDITIONAL INSURANCE?
  • Birthdate
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  • Date Employed
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  • Format: (000) 000-0000.

  • Patient Medical History

  • Format: (000) 000-0000.
  • Date of Last Exam
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  • Are you under medical treatment now?
  • Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
  • Are you taking any medication(s) including non-prescription medicine?
  • Have you ever taken Fen-Phen/Redux?
  • Do you use tobacco?
  • Do you use controlled substances?
  • Are you wearing contact lenses?
  • Rows
  • Rows
  • Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

  • Women Only:

  • Are you pregnant or think you may be pregnant?
  • Are you nursing?
  • Are you taking oral contraceptives?

  • Patient Dental History

  • Date of Last Exam
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  • Do your gums bleed while brushing or flossing?
  • Are your teeth sensitive to hot or cold liquids/foods?
  • Are your teeth sensitive to sweet or sour liquids/foods?
  • Do you feel pain to any of your teeth?
  • Do you have any sores or lumps in or near your mouth?
  • Have you had any head, neck or jaw injuries?
  • Have you ever experienced any of the following problems in your jaw?
  • Do you have frequent headaches?
  • Do you clench or grind your teeth?
  • Do you bite your lips or cheeks frequently?
  • Have you ever had any difficult extractions in the past?
  • Have you ever had any prolonged bleeding following extractions?
  • Have you had any orthodontic treatment?
  • Do you wear dentures or partials?
  • Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
  • Do you like your smile?

  • Authorization and Release

  • Payment is due in full at the time of treatment unless prior arrangements have been approved. This office accepts insurance. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby acknowledge release of any information, including the diagnosis and records of treatment or examination needed, to my insurance company.

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

  • Date
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  • Our Policy Regarding Dental Insurance

  • Whether you have purchased dental insurance on your own or your employer has provided it to you, you are fortunate to have it and we will go the extra mile to help you maximize your benefits provided by your specific plan. If you wish, we will also be glad to help you file your insurance forms which will save you considerable time and trouble. Your insurance company usually only pays a percentage of the fee, or the usual and customary fee, and this varies from plan to plan. Your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost. A better term for dental insurances may be “dental assistance”.

    Please remember however, the financial obligation for the dental treatment is between you and this office, and is not between us and the insurance company.

    On rare occasions, a dental insurance plan will require a “Predetermination” or “Prior Authorization” for treatment, though most insurance companies do not require this. If they do, we will be happy to submit a treatment plan to your insurance carrier on request. In order for us to submit this form, we ask that you provide the following.

     

    1. A copy of insurance booklet and/or a copy of your insurance card.
    2. A copy of a signed insurance form with the insured’s birth date, social security number, group and/or ID number, and the name of the employee, whichever is applicable.

     

    I have read and understand that I am responsible for any and all treatment regardless of the insurance billing outcome. I further understand I will have to pay for treatment, collection fees, lawyer fees and any expenses incurred to collect the debt.

  • Date
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  • NOTICE OF PRIVACY PRACTICES

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

     

    OUR LEGAL DUTIES

    We are required by law to maintain the privacy of your Protected Health Information (PHI) and to provide you with this Notice of our legal duties and privacy practices. We must follow the terms of this Notice while it is in effect. In the event of a breach of your unsecured PHI, we will notify you promptly.

    I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND OPERATIONS

    We may use and disclose your PHI for the following purposes without your written authorization:

    Treatment: We may use and disclose your PHI to provide, coordinate, or manage your dental care. Example: We may share your PHI with a specialist, such as an oral surgeon, or a dental laboratory to create your crown.

    Payment: We may use and disclose your PHI so that we can bill and collect payment for the treatment and services you receive. Example: We provide information about your dental cleaning to your insurance company so they can process the payment.

    Healthcare Operations: We may use and disclose your PHI for our practice operations. Example: Using your information to conduct quality assessments, train staff, or send appointment reminders.

    II. USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW

    In certain circumstances, we are permitted or required by federal and Vermont law to disclose your PHI without your authorization:

    • Public Health and Safety: To prevent or control disease, report adverse medication reactions, or notify a person at risk of contracting a communicable disease.
    • Abuse or Neglect: To report suspected child abuse, neglect, or domestic violence to authorized government agencies.
    • Law Enforcement: In response to a court order, subpoena, warrant, or other legal process.
    • Health Oversight: To agencies for audits, investigations, or inspections necessary for government monitoring of the healthcare system.
    • Judicial and Administrative Proceedings: If you are involved in a lawsuit, we may disclose PHI in response to a valid court or administrative order.
    • Workers’ Compensation: To comply with Vermont workers’ compensation laws for work-related injuries.
    • Military and National Security: As required by military command or for national security and intelligence activities.

    III. SPECIAL PROTECTIONS FOR MINORS AND LEGAL GUARDIANS

    Under Vermont law, the rights of minors and parents are uniquely protected:

    • Parental Access: A parent or guardian is generally the minor’s “personal representative” and can access the minor’s records.
    • Custody: Per Vermont law, a parent cannot be denied access to records solely because they do not have primary physical custody, unless a specific court order states otherwise.
    • Minor Consent: Vermont minors age 12 and older may independently consent to diagnosis and treatment for substance use disorders or sexually transmitted diseases. In these cases, the minor—not the parent—controls the records related to that care.
    • Provider Discretion: We may withhold a minor’s information if we believe disclosure would endanger the child or another person.

    IV. SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER (SUD) RECORDS

    Beginning February 16, 2026, federal law (42 CFR Part 2) provides enhanced protections for SUD records received from federally assisted programs:

    • Restricted Use: SUD records or testimony about them shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings without your written consent or a specific court order.
    • Consent: If we receive SUD records via your general consent for treatment, payment, or operations, we will only use and disclose them as permitted by that consent or federal law.

    V. YOUR INDIVIDUAL RIGHTS

    You have the following rights regarding the PHI we maintain about you:

    • Inspect and Copy: You may request to see and get a paper or electronic copy of your dental and billing records.
    • Amend Records: You may request in writing that we correct information you believe is inaccurate or incomplete.
    • Accounting of Disclosures: You may ask for a list of certain disclosures we have made of your PHI for purposes other than treatment, payment, or operations.
    • Request Restrictions: You may ask us not to use or share certain PHI. If you pay in full out-of-pocket, we must agree not to share that information with your health insurer.
    • Confidential Communications: You may request that we contact you in a specific way (e.g., home phone) or at a specific address.

    VI. COMPLAINTS AND CONTACT INFORMATION

    If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or the Secretary of the U.S. Department of Health and Human Services (HHS). We will not retaliate against you for filing a complaint.

    Privacy Officer: Office Manager

    Phone: 802-655-5305

    Address: 905 Roosevelt Hwy, Suite 230, Colchester, VT 05446

  • ACKNOWLEDGMENT OF RECEIPT

    NOTICE OF PRIVACY PRACTICES

  • Sunny Hollow Dental, Lee J. Weltman, D.D.S.

    905 Roosevelt Hwy. Suite 230, Colchester, VT 05446
    Phone: 802-655-5305

    I, , have been presented with a copy of the comprehensive Notice of Privacy Practices for Sunny Hollow Dental, Lee J. Weltman, D.D.S., effective February 16, 2026.

    I understand that this Notice describes how my health information (including dental records, billing information, and any protected substance use disorder records) may be used and disclosed, and how I can access this information. I acknowledge that I have been informed of my rights under the HIPAA Privacy Rule and applicable Vermont State Laws.

    I understand that I am entitled to receive a paper or electronic copy of this document at any time upon request.

  • Date
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  • PATIENT PERMISSION TO RELEASE INFORMATION

  • IF YOU PERMIT SOMEONE ELSE TO CALL

    Regarding your Dental Health, your account or scheduling or cancelling
    Please write their name and address below and relation:

  • Date
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