We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any question we'll be glad to help you.
ADDRESS AND HOME PHONE
INSURANCE POLICY 1
Please present insurance card to receptionist
INSURANCE POLICY 2
Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person bringing your child will need to present a photo identification at each time of service.This authorization gives the person listed below permission to bring your child(ren) to appointments and speak to the doctor regarding protected health information. Furthermore, this authorization allows the person(s) listed below the authority to give authorization and consent for all general dental and health decisions with no restrictions
I also understand I am responsible for any expenses incurred in my absence.
(IF ONLY PARENTS CAN BRING CHILD IN, PLEASE INDICATE 'NONE')
I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature and not enough time to seek out my specific consent. This consent will remain in effect until, I notify Lawrenceville Pediatric Dentistry in writing.For any questions regarding this consent please contact me at the below information. I will try to stay available during my child(ren)'s appointment time to answer any questions that may arise.
Parents: Prevailing medical/dental practice law requires that we ask you to read the following and sign at the bottom of the page. We apologize in advance for the impersonal nature of this form.
and have legal authority to give consent for medical/dental treatment for him/her.2. I give my consent to Dr. Shikha Sharma to render dental and/or any emergency medical procedures deemed necessary or advisable.3. I give my consent to use local anesthetics, nitrous oxide (laughing gas), radiographs (Xrays), fluoride, fillings, extractions, stainless steel (silver) crowns, nerve treatment, photographs as needed for diagnosis, patient records and insurance requirements or documentation. 4. The aspects of dental treatment have been previously explained to me to my satisfaction: the procedures, the benefits and disadvantages of treatment, any alternatives, possible side effects and complications, as well as the prognosis if no treatment is provided.
6. I understand that in the course of treatment my child may become uncooperative and restraint may be necessary (e.g. hand holding) to safely complete treatment. I also understand that I will be informed during and after treatment if this is necessary.7. I understand that, although good results are expected, the possibility and nature of complications cannot always be accurately anticipated. Therefore, there is no guarantee expressed or implied either to the result of the treatment or as to the cure.8. I have been given an opportunity to ask any questions I might have.9. This consent will be in force indefinitely until rescinded by me.10. I have read, and I understand this consent form.
The terms of this Notice of Privacy Practices (“Notice”) apply to Lawrenceville Pediatric Dentistry, LLC, its affiliates, and its employees. Lawrenceville Pediatric Dentistry will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Lawrenceville Pediatric Dentistry. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.
Authorization and Consent: Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc.
Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation, and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving clinical treatment and patient care.
Individuals Involved in Your Care: We may from time to time disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information.
Appointments and Services: We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a address, we will accommodate reasonable requests. With such request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below.
Research: In limited circumstances, we may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of your information.
Fundraising: We may use your information to contact you for fundraising purposes. We may disclose this contact information to a related foundation so that the foundation may contact you for similar purposes. If you do not want us or the foundation to contact you for fundraising efforts, you must send such request in writing to the Privacy Officer at the address below.
Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:
Psychotherapy Notes: We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which we may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.
Genetic Information: We must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment, or health care operations purposes. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law.
Marketing: We must obtain your authorization for any use or disclosure of your protected health information for marketing, except if the communication is in the form of (1) a face-to-face communication with you, or (2) a promotional gift of nominal value.
Sale of Protected Information: We must obtain your authorization prior to receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for:
Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made in writing and signed by you or your legal representative. You may obtain a "Patient Access to Health Information Form" from the front office person. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies you will be charged a fee for copying and postage.
Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make requested amendments, but we will give each request careful consideration. All amendment requests, must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an "Amendment Request Form" from the front office person or individual responsible for medical records.
Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. "Accounting Request Forms" are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.
Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. We are not required to agree to most restriction requests but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid [Practice Name] in full. If we agree to any discretionary restrictions, we reserve the right to remove such restrictions as we appropriate. We will notify you if we remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records.
Right to Notice of Breach: We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.
Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to the Privacy Officer at the address below.
Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.
For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the Lawrenceville Pediatric Dentistry Privacy Officer by phone at 678-629-3663 or at the following address: 4850 Sugarloaf parkway, Suite 611 Lawrenceville Ga 30044. This Notice of Privacy Practices is also available on our Lawrenceville Pediatric Dentistry web page at www.Lawrencevillekidsdentist.com.
I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.
As the parent or guardian of the child/children at LAWRENCEVILLE PEDIATRIC DENTISTRY, I agree to the following:
I understand that my child(ren) whose name(s) are listed below may be photographed at LAWRENCEVILLE PEDIATRIC DENTISTRY during normal hours and treatments. I understand that the photographs may be used in promoting dental services, either in print or on the Internet.
Please mark ‘YES’ if your child has history of the following conditions. For each Yes please provide explanation in the line at the bottom of the list. Please mark ‘NO’ if none of these conditions apply to your child.
I understand the above information in necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
I understand that:
DISMISSAL FROM OUR OFFICE:
Unfortunately, we must dismiss patients who:
If you have any questions regarding these policies, please do not hesitate to ask the front desk receptionists. I understand and agree with the above stated policies regarding appointments and dismissal procedures. I have also been given a copy of the "Notice of Privacy Practices” brochure.