Confidential Patient Information
Confidential Responsible Party Information
My Kid's Smile Confidential Patient Medical and Dental History
I certify that the above information is complete and accurate.
Our Mission: "Quality Care and a Positive Patient Experience"
The doctors and staff at My Kid's Smiles have an unwavering commitment to your child's superior oral health. We use sound scientific and ethical principles in order to provide your child with the highest standard of pediatric dental care available in our area. We also recognize that creating a fun, friendly, and comfortable environment is critical to the child's long-term oral health. We know you have a choice in dental providers and we hope that these goals are the primary reasons you have chosen our practice. Please keep in mind that all of the following policies center on accomplishing these two core philosophies.
Late Appointment Policy
We ask that all parents make a special effort to be at their child's appointments on time in order to minimize the impact on their child's care and dental experience as well as that of those patients scheduled later in the day. If a patient is more than 10 minutes late to a 30 minute appointment or 15 minutes late to a 60 minute appointment they may be required to reschedule or wait while we care for those patients who were on time to their appointments. Regular tardiness will lead to the end of the doctor-patient relationship.
Missed or Cancelled Appointment Policy
Due to the busy nature of our practice and as a common courtesy to the doctors and staff who are providing important care to your child, we ask that you please make your child's appointment a top priority. If you are unable to make your appointment please give us sufficient time to fill your child's appointment with another child waiting to see the doctor. We ask that you call to reschedule or cancel 24 hours in advance. A second last minute cancellation or no-show will lead to the end of the doctor-patient relationship.
Insurance and Financial Policy
In most cases insurance companies do not pay for 100% of the care needed by our patients. Should there be a difference between the costs of the dental care provided to your child by My Kid's Smile and the amount your insurance company reimburses the difference will be your responsibility. At your request, we will do all we can to help you understand and maximize the benefits available to you through your insurance provider, but ultimately it is your responsibility to understand the coverage of your policy prior to care being provided and charges incurred.
Our top priority is to give you all the information needed to make informed decisions in regards to your child’s oral health. This includes providing you with the nature of recommended procedures, the risks of those procedures, any alternatives to the procedures recommended, and an estimate of the costs involved to perform those procedures.
We hope that open communication is important to you as well and that any concerns you have about treatment or our policies will be brought immediately to our attention with the same courtesy and respect. We will sincerely do all we can to develop a long-term relationship where your child’s oral health and dental experience is number one for both of us.
I HAVE READ, UNDERSTAND, AND AGREE TO MY KID'S SMILE KEY PRACTICES POLICIES. (SIGN BELOW)
January 1, 2018 NOTICE OF PRIVACY PRACTICES My Kid’s Smile 10645 Double R Blvd, Reno, NV 89521 1130 North Hills Blvd, Reno, NV 89506 5030 Las Brisas Blvd, Reno, NV 89523 3150 Vista Blvd, Sparks, NV 89436 email@example.com
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. We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
• when a state or federal law mandates that certain health information be reported for a specific purpose; • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; • uses or disclosures for health related research; • uses and disclosures to prevent a serious threat to health or safety; • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; • disclosures of de-identified information; • disclosures relating to worker's compensation programs; • disclosures of a "limited data set" for research, public health, or health care operations; • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; • disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information; Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.
APPOINTMENT REMINDERS We may call, email, text or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call, email, text, or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we may leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can:
• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice. • ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICESBy law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.
COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for any other reason we will request your written.
I, First and Last Name , give my permission for My Kid's Smile to perform dental procedures including nitrous and local anesthetic within the professional scope of dentistry deemed as necessary on my child/children to individuals with my permission. I give my permission to the following individuals to bring in my child/children to My Kid's Smile for their appointments that may include any and all dental procedures.
I, blanks , acknowledge the understanding that dentistry is not an exact science and herby request and authorize whatever the doctor deems advisable if any unforeseen condition arises in the course of these designated treatment(s) and/or procedures calling, in their judgment, for procedures in addition to or different from those contemplated. In addition, I have provided as accurate and complete medical history as possible including those antibiotics, drugs, medications and foods to which my child is allergic.