Dental History

THIS NOTICE DESCRIBES HOW HEALTH 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.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003 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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available 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.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example,

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you .

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations, Healthcare operations Include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information. we will provide, you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

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

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practice

Patient (Representative) Signature

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Your exported signature

Date:

Date:

Authority of Personal Representative to Sign for Patient (please circle):

Parent Guardian Power of Attorney Other:

Insurance Policy

Patients using dental insurance are hereby advised that your insurance is filed as a courtesy, not a requirement. In the event your insurance company has not paid the claim within sixty days, any unpaid charges become the responsibility of the patient, as does following up with the insurance company.

Patient / Guardian Signature

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Your exported signature

Patient Name:

Patient Name:

Date:

Date:

Appointment Cancellation Policy

Dove Dental Specialists is always committed to providing exceptional care and service. Due to an increased demand for appointments, we must receive notice by 2:00 p.m. two business days prior to your scheduled appointment to inform us of any changes or cancellations. To cancel a Monday appointment, please call our office by 2:00 p.m. on Thursday.

If prior notification is not given, you will be assessed $50 for the missed appointment. It is the responsibility of the patient to keep track of their appointments, a reminder call is a courtesy. If you are not here at your specified appointment time, we will have to reschedule you.

Please prepare to arrive 10 minutes prior to your appointment to avoid rescheduling.

Thank you for your understanding in these unprecedented times.

Appointment Confirmation Agreement

Please be aware if confirmation for your for your appointment has not been received by 2:00p.m. two business days prior, your appointment will be forfeited.

Patient / Guardian Signature

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Your exported signature

Patient Name:

Patient Name:

Date:

Date:

Authorization for Release of Information to Family Members

Patient Name:

Patient Name:

Phone Number:

Phone Number:

I authorize Dove Dental Specialists to release my medical and/or billing information to the following individual(s):

Name:

Name:

Relation to Patient :

Relation to Patient:

Name:

Name:

Relation to Patient :

Relation to Patient :

Patient Signature

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Your exported signature

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorise the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature:

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Your exported signature

Date:

Date: