Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Medical History

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being.

Would you consider yourself to be in fairiy good health?
Yes
No
Within the past year, have there been any changes in your general health?
Yes
No

Please mark any of the following to indicate Yes in response to the question

Have you ever had complications following dental treatment?
Yes
No
Are you currently under care of a physician due to a specific condition?
Yes
No
Have you been hospitalized within the ast 5 years due to a surgery or illness?
Yes
No
Are you currently taking any prescription or non-prescription medications?
Yes
No
Do you use tobacco (smoking or chewing)?
Yes
No
Do you require the use of corrective lenses (contacts or glasses)?
Yes
No
Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
Yes
No
I have answered all the above questions

Medical History

Yes No
Pre-Med
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Please indicate if you have experienced any of the following:

Anemia
Yes
No
Arthritis
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Cancer
Yes
No
Diabetes
Yes
No
Dizziness
Yes
No
Epilepsy
Yes
No
Excessive Bleeding
Yes
No
Fainting
Yes
No
Glaucoma
Yes
No
Head Injuries
Yes
No
Heart Disease
Yes
No
Heart Murmer
Yes
No
Hepatitis
Yes
No
High Blood Pressure
Yes
No
HIV
Yes
No
Jaundice
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Mental Disorders
Yes
No
Nervous Disorders
Yes
No
Other
Yes
No
Pacemaker
Yes
No
Pregnancy
Yes
No
Radiation Treatments
Yes
No
Respiratory Problems
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Sinus Trouble
Yes
No
Stomach Problems
Yes
No
Stroke
Yes
No
Tuberculosis
Yes
No
Tumors
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
I have answered all the above questions

What is the reason for your dental visit today?
3(+)a day Twice a day Once a day Weekly Seldom
1(+)a day 2-6 weekly 1-6 monthly Seldom Never

Do your gums bleed when you brush or floss?
Yes
No
Do your teeth experience sensitivity to cold or hot temperatures?
Yes
No
Are any of your teeth currently causing' you pain?
Yes
No
Do you grind your teeth (either consciously or during sleep)?
Yes
No
Are any of your teeth loose. or are you concerned about any teeth loosening?
yes
No
Do you currently have any dental imp4-its, dentures, or partials?
Yes
No
Are Your Teeth Sensitive to?
Yes
No
If any of previous questions are marked, Please explain
If you could change anything about your mouth,teeth, or smile, what would it be?
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully convered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Consent for Internet Communications

I grant permission to Brannon Crossing Family Dental in Brannon Crossing, Nicholasville, KY to upload and store confidential patient information, including but not limited to account information, appointment information, and clinical information, to the secured website for Brannon Crossing Family Dental in Brannon Crossing, brannoncrossingfamilydental.com. I understand that the site will require a usemame and password for access and use. I further understand that I am responsible for maintaining the strict confidentiality of any ID and password assigned to me and that Brannon Crossing Family Dental in Brannon Crossing is not liable for any charges, damages, or losses that may be a result of my failure to maintain confidentiality. Brannon Crossing Family Dental in Brannon Crossing is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the website with my ID and password. I understand that I am responsible for immediately notifying Brannon Crossing Family Dental in Brannon Crossing of any unauthorized use of my ID or of any other cause for deactivating my ID due to security concerns.

I understand that state and federal laws, as well as the ethical and licensure requirements, require patient confidentiality that limits the ability of make use of certain electronic services or the transmission of certain information to third parties. I understand that Brannon Crossing Family Dental in Brannon Crossing represents and warrants that they will, at all times, during the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, use their best efforts to cause all persons or entities under their direction or control to comply with such laws and regulations. I agree that Brannon Crossing Family Dental in Brannon Crossing has the right to monitor, retrieve, store, upload, and use my patient information in connection with the operation of such services and is acting on my behalf in uploading my patient information for my use on the website.

I have read the above information regarding the secured uploading of patient information to the website for Brannon Crossing Family Dental in Brannon Crossing, Brannoncrossingfamilydental.com, and grant permission to securely upload my patient information to the website. By checking the box and hitting submit button, I agree to communication via the Internet.

No show policy

In order to be respectful of the medical needs of our patients, we have incorporated a cancellation/no show policy. Please read the following carefully, then sign that you have been informed of the policy.
If it is necessary to cancel/reschedule your appointment, we require that you call 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.
A no show" is someone who missed an appointment without cancelling 24 hours in advance. A failure to present at the time of a scheduled appointment will be recorded in the patients' chart as a "no show". An administrative fee of S25.00 will be billed to the patient account. We value our patient relationships and will do everything we can to accommodate you. Your communication and compliancy are not only very much appreciated but will help us to help you (and others) achieve a positive outcome.

I acknowledge that I have been informed of the Cancellation/No Show Policy.

By checking this box, I acknowledge that I have read the above information regarding the no-show policy.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Hippa

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 1/2/13, 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 informationWe 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 dentist, 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. By state law, your authorization is valid for 90 days.

-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 you 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 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.

-National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

-Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

-Patient RightsAccess: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we may charge you S0.80 for each page up to thirty (30) and $0.60 for each page after thirty, a S20 administrative fee to locate and copy your health information, and postage if you want the copies mailed to you. Radiographs (x-rays) will be duplicated at a reasonable fee. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
-Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before January 2, 2013. If you request this accounting more than once in a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests.

-Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
-Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to altemative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

-Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

-Electronic Notice: If you receive this Notice on a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Questions and Complaints
If you want more information about our privacy practices or has questions or concerns, please contact us.
If you are concemed that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by altemative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

By checking hereyou acknowledge you have read the Notices of Privacy Acts
SIGNATURE
 
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(Your IP Address : )

Office Financial Policy

Brannon Crossing Family Dental is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy which we require you are read and sign prior to any treatment. All patients must complete our Patient Information form before seeing the doctor.
Our financial policy is as follows:
-We accept cash, personal checks, Visa, MasterCard, and JCB card.
-Payment is due at the time of services are rendered unless prior arrangements have been made with the doctor and the billing receptionist.
- Extended treatment plans will be outlined so that appropriate payments may be made as each phase of treatment is begun.
-If dentures, partial dentures, crown and bridge are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted.
-Insurance: Insurance is a contract between the patient and/or employer and the insurance company. It is NOT a contract between our office and your insurance company. We will be happy to assist you by filing your insurance claim and answering the details that the insurance company may require. We cannot be responsible for payment by the insurance company. You agree to pay any portion of the charges for services rendered but not covered by your plan or not paid (denied) by your insurance.
We will provide estimated balances between the cost of service and co-payment of your insurance. Any deductible or estimated co-payment amount will be due at the time of service.
If your insurance company has not paid the full balance within 45 days, you will have 15 days to pay the balance. A monthly financial charge of 1.5% will be added to any unpaid balances after 60 days from date of services.

- Retum Checks: Returned Check fee of S35.00 will be added to your account balance. I have read the Financial Policy.

By checking the box, I have read and agree to the financial policy as discribed above.
SIGNATURE
 
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Thank you for visiting Brannon Crossing Family Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:     First Name:     MI:     Last Name:     Preferred Name:    
Date Of Birth:     Social Security Number:    
Gender:     Marital Status:     Prev. Visit     Best time to call    

Address

Street Address:     City:     State:     Zip:    
Home Phone:     Ext Phone:     Work Phone:     Mobile:     Fax:     Others:    
Email Address:    
Whom may we thank for referring you to our practice?
Dental Office Yellowpages TV Ad
Internet Newspaper Radio
Work Others

The following is for
The patient's spouse The person responsible for payment neither-not applicable
Title:     First Name:     MI:     Last Name:     Preferred Name:     Gender:     Marital Status:     Date Of Birth:     Driver's License:     Social Security Number:    
Home Phone:     Work Phone:     Ext Phone     Fax     Other    
Address:     City:     State:     Zip Code:    

Primary Insurance Information

First Name     MI     Last Name     Insured Birth Date:     Relation:     ID:     Group (Plan , Local , Policy):    
Insurance Co.Address:     City:     State:     Zip Code:    
Insured's Employer Name:    
Employer's Address:     City:     State:     Zip Code:    
Insurance Co. Name:    
Insurance Co.Address:     City:     State:     Zip Code:    

Secondary Insurance Information

First Name     MI     Last Name     Insured Birth Date:     Relation:     ID:     Group (Plan , Local , Policy):    
Insurance Co.Address:     City:     State:     Zip Code:    
Insured's Employer Name:    
Employer's Address:     City:     State:     Zip Code:    
Insurance Co. Name:    
Insurance Co.Address:     City:     State:     Zip Code:    
Medical History
Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being.
Within the past year, have there been any changes in your general health?
Yes
No
What is the date (or approximate date) of your last medical exam?
Yes
No
What is the date (or approximate date) of your last medical exam?    
Your Primary Care Physician's name, address, & phone number:    
Please mark any of the following to indicate Yes in response to the question
Have you ever had complications following dental treatment?
Yes
No
Are you currently under care of a physician due to a specific condition?
Yes
No
Have you been hospitalized within the ast 5 years due to a surgery or illness?
Yes
No
Are you currently taking any prescription or non-prescription medications?
Yes
No
Do you use tobacco (smoking or chewing)?
Yes
No
Do you require the use of corrective lenses (contacts or glasses)?
Yes
No
Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
Yes
No
If any of the previous questions are marked, please explain:    
WOMEN ONLY: Are you pregnant?
Yes
No
If YES, When is the due date?    
Pre-Med
Amox Clind Other
Are you allergic to any of the following?
Aspirin Codeine Erythro Hay Fever
Latex Others Penicillin Sulfa drugs
Do you or Have you experienced the following ?
Anemia Arthritis Artificial Joints
Asthma Blood Disease Cancer
Diabetes Dizziness Epilepsy
Excessive Bleeding Fainting Glaucoma
Head Injuries Heart Disease Heart Murmer
Hepatitis High Blood Pressure HIV
Jaundice Kidney Disease Liver Disease
Mental Disorders Nervous Disorders Other
Pacemaker Pregnancy Radiation Treatments
Radiation Treatments Respiratory Problems Rheumatic Fever
Rheumatism Sinus Trouble Stomach Problems
Stroke Tuberculosis Tumors
Ulcers Venereal Disease
Do you have any other health issue or allergies?    
Dental History
What is the reason for your dental visit today?
   
When was your last visit to be dentist(if to a diffrent office?)
   
When was done on your last dental visit(if to a diffrent office?)
   
Prior Dentist's name, address & phone number
   
How frequently do you brush your teeth? 3(+)a day Twice a day Once a day Weekly Seldom
How frequently do you floss your teeth? 1(+)a day 2-6 weekly 1-6 monthly Seldom Never
Do your gums bleed when you brush or floss?
Yes
No
Do your teeth experience sensitivity to cold or hot temperatures?
Yes
No
Are any of your teeth currently causing' you pain?
Yes
No
Do you grind your teeth (either consciously or during sleep)?
Yes
No
Are any of your teeth loose. or are you concerned about any teeth loosening?
Yes
No
Do you currently have any dental imp4-its, dentures, or partials?
Yes
No
Are Your Teeth Sensitive to?
Yes
No
If any of previous questions are marked, Please explain If you could change anything about your mouth,teeth, or smile, what would it be?
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Treatment Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully convered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

The information on this page is correct to the best of my knowledge.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Consent for Internet Communications

I grant permission to Brannon Crossing Family Dental in Brannon Crossing, Nicholasville, KY to upload and store confidential patient information, including but not limited to account information, appointment information, and clinical information, to the secured website for Brannon Crossing Family Dental in Brannon Crossing, brannoncrossingfamilydental.com. I understand that the site will require a usemame and password for access and use. I further understand that I am responsible for maintaining the strict confidentiality of any ID and password assigned to me and that Brannon Crossing Family Dental in Brannon Crossing is not liable for any charges, damages, or losses that may be a result of my failure to maintain confidentiality. Brannon Crossing Family Dental in Brannon Crossing is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the website with my ID and password. I understand that I am responsible for immediately notifying Brannon Crossing Family Dental in Brannon Crossing of any unauthorized use of my ID or of any other cause for deactivating my ID due to security concerns.

I understand that state and federal laws, as well as the ethical and licensure requirements, require patient confidentiality that limits the ability of make use of certain electronic services or the transmission of certain information to third parties. I understand that Brannon Crossing Family Dental in Brannon Crossing represents and warrants that they will, at all times, during the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, use their best efforts to cause all persons or entities under their direction or control to comply with such laws and regulations. I agree that Brannon Crossing Family Dental in Brannon Crossing has the right to monitor, retrieve, store, upload, and use my patient information in connection with the operation of such services and is acting on my behalf in uploading my patient information for my use on the website.

I have read the above information regarding the secured uploading of patient information to the website for Brannon Crossing Family Dental in Brannon Crossing, Brannoncrossingfamilydental.com, and grant permission to securely upload my patient information to the website. By checking the box and hitting submit button, I agree to communication via the Internet.

No show policy

In order to be respectful of the medical needs of our patients, we have incorporated a cancellation/no show policy. Please read the following carefully, then sign that you have been informed of the policy.
If it is necessary to cancel/reschedule your appointment, we require that you call 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.
A no show" is someone who missed an appointment without cancelling 24 hours in advance. A failure to present at the time of a scheduled appointment will be recorded in the patients' chart as a "no show". An administrative fee of S25.00 will be billed to the patient account. We value our patient relationships and will do everything we can to accommodate you. Your communication and compliancy are not only very much appreciated but will help us to help you (and others) achieve a positive outcome.

I acknowledge that I have been informed of the Cancellation/No Show Policy.

By checking this box, I acknowledge that I have read the above information regarding the no-show policy.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Hippa

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 1/2/13, 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 informationWe 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 dentist, 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. By state law, your authorization is valid for 90 days.

-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 you 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 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.

-National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

-Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

-Patient RightsAccess: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we may charge you S0.80 for each page up to thirty (30) and $0.60 for each page after thirty, a S20 administrative fee to locate and copy your health information, and postage if you want the copies mailed to you. Radiographs (x-rays) will be duplicated at a reasonable fee. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
-Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before January 2, 2013. If you request this accounting more than once in a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests.

-Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
-Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to altemative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

-Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

-Electronic Notice: If you receive this Notice on a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Questions and Complaints
If you want more information about our privacy practices or has questions or concerns, please contact us.
If you are concemed that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by altemative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

By checking hereyou acknowledge you have read the Notices of Privacy Acts
 
  
 
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Office Financial Policy

Brannon Crossing Family Dental is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy which we require you are read and sign prior to any treatment. All patients must complete our Patient Information form before seeing the doctor.
Our financial policy is as follows:
-We accept cash, personal checks, Visa, MasterCard, and JCB card.
-Payment is due at the time of services are rendered unless prior arrangements have been made with the doctor and the billing receptionist.
- Extended treatment plans will be outlined so that appropriate payments may be made as each phase of treatment is begun.
-If dentures, partial dentures, crown and bridge are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted.
-Insurance: Insurance is a contract between the patient and/or employer and the insurance company. It is NOT a contract between our office and your insurance company. We will be happy to assist you by filing your insurance claim and answering the details that the insurance company may require. We cannot be responsible for payment by the insurance company. You agree to pay any portion of the charges for services rendered but not covered by your plan or not paid (denied) by your insurance.
We will provide estimated balances between the cost of service and co-payment of your insurance. Any deductible or estimated co-payment amount will be due at the time of service.
If your insurance company has not paid the full balance within 45 days, you will have 15 days to pay the balance. A monthly financial charge of 1.5% will be added to any unpaid balances after 60 days from date of services.

- Retum Checks: Returned Check fee of S35.00 will be added to your account balance. I have read the Financial Policy.

By checking the box, I have read and agree to the financial policy as discribed above.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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