Child New Patient Form Step 1 of 2 50% Patient First Name(Required) Middle Initial Last Name(Required) Preferred Name Date of Birth(Required) MM slash DD slash YYYY Gender Male Female Who should we thank for referring your family to our office? Responsible Party informationParent/Guardian #1 Name Date of Birth MM slash DD slash YYYY Marital Status Relationship to patient Preferred PhoneCellHomeWorkPhoneAlternate PhoneEmployer Email Home Address City State Zip Parent/Guardian #2 Name Date of Birth MM slash DD slash YYYY Marital Status Relationship to patient Preferred PhoneCellHomeWorkPhoneAlternate PhoneEmployer Email Home Address Same as above Other Street City State Zip Child Lives with Both Guardian #1 Guardian #2 Other Specify Other The Parent/Guardian who is bringing the patient to the appointment is responsible for paymentINSURANCE INFORMATIONPrimary Insurance Company Policy NumberName of Subscriber Date of Birth MM slash DD slash YYYY Group NumberSecondary Insurance Company Policy NumberName of Subscriber Date of Birth MM slash DD slash YYYY Group NumberI hereby authorize any associate of Gifford Family Dentistry to release any and all dental information to process my insurance claim. I hereby authorize my insurance company to pay directly to Gifford Family Dentistry all dental benefits due me, by reason of dental services rendered. I understand l am financially responsible to the dentist for charges not covered by this authorization. SignaturePrint Name Relation to Patient Date MM slash DD slash YYYY PATIENT MEDICAL HISTORYPatient's Pediatrician/Physician Practice name Pediatrician/Physician Phone NumberCurrent Medications None List Please SpecifyAllergies (food/drug/latex) None List Please SpecifyHas the patient ever had any of the following conditions?Acid Reflex/GI Problems Yes No Anemia Yes No Asthma Yes No Autism Yes No Birth Defects Yes No Bleeding Problems Yes No Blood Disorders Yes No Cancer Yes No Cerebral Palsy Yes No Diabetes Yes No Down Syndrome Yes No Epilepsy/Seizures Yes No Emotional Problems Yes No Heart Condition Yes No Heart Murmur Yes No Hepatitis Yes No HIV/AIDS Yes No Hyperactivity/ADHD Yes No Immune Disorder Yes No Intellectual Disability Yes No Kidney Disease Yes No Liver Disease Yes No Learning Disabilities Yes No Psychiatric Problems Yes No Rheumatic Fever Yes No Skin Disorders Yes No Sickle Cell Anemia Yes No Sleep Apnea/Snoring Yes No Spina Bifida Yes No Speech/Hearing Yes No Tuberculosis Yes No Tonsils/Adenoids removed Yes No Please elaborate on any of the above or list any other health problems/special concernsPATIENT DENTAL HISTORYAge of 1st dental visit Previous Dentist/Office Name (if applicable) Main reason for today's visit How often are the child's teeth brushed? 2x/day 1x/day less than daily How often are the child's teeth being flossed? 1x/day less than daily Who does the brushing and flossing? Parent Child Half/Half Total Fluoride Use? Rx by MD/DMD in H2O Toothpaste Rinse None When was your child weaned off nursing/bottle? 6 months 12 months 24 months Still use Does your child have any oral habits? Thumb/finger Binky Mouth breather History of dental trauma? Yes No If Yes, please explainHow would you rate mother's oral health? Excellent Good Fair Poor I don't know How would you rate father's oral health? Excellent Good Fair Poor I don't know How would you rate your child's sweets consumption? Low Average High Is there any additional medical/dental information you may want Dr. Gifford to know?I have read and understand the above questions and have answered them to the best of my ability. If there are any changes to the patient's health status, I will inform the dentist and staff. Parent/Guardian SignatureDate MM slash DD slash YYYY Print Name Dr /RDH SignatureFinancial Policy (Effective Date: June 14, 2014)Thank you for choosing Gifford Family Dentistry. Our team takes pride in providing every patient with the best possible dental care. We want you to feel as comfortable as possible throughout your treatment. This includes understanding your treatment plan as well as our financial policy. Do You Accept My Insurance? How Much Will They Pay? We currently work with most private dental benefit plans. The amount of coverage that your benefit plan provides is negotiated between your employer and the insurance company. Payment of benefits for provided treatment is never guaranteed by the insurance companies. Therefore, it is impossible to give you a guaranteed quote prior to or at the time of service, even if the services are preauthorized. We estimate your portion based on the most up-to-date information we have, but it is still only an estimate. We will always make a diligent of to collect the full portion due from your insurance company. We accept and bill your insurance churning assignment of benefits. What this means is your insurance will pay our office directly and we will apply it to your claim accordingly. If your insurance does not accept the assignment of benefits and pays you directly, it is your obligation to forward that payment to our office to assign their portion of the claim. PATIENT INITIALS My Insurance Did Not Pay Now What? Please keep in mind that a dental benefit plan is a contract between you, your employer, and the insurance company. We will bill your insurance company as a courtesy to you; however, while we will attempt to help you understand your plan, it is your obligation to know your insurance plan, exclusions, limitations, and ultimately pay for any treatment your insurance company refuses to cover.PATIENT INITIALS Minor Patients The adult(s) accompanying it minor and the parent(s) (or guardians of the minor) are responsible the full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been re-authorized to an approved credit plan, credit card, or payment by cash or check at the time the service has been verified. In the case of divorce or separation, the party responsible for the account prior to the divorce or separation remains the responsible party. After a divorce or separation, the parent authorizing the treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent. We are unable to place a parent or guardian on an account, as the responsible party, without the express, written authorization from that parent. PATIENT INITIALS Financial Responsibility Your estimated portion is due at the time of service. We accept cash, checks, Visa, MasterCard, And Care Credit. Finance Charges: All past due balances (60 days and greater) are subject to finance charges of 12% APR, or a minimum of $5 per month. This is to offset the costs associated with repeated billing of statements. Broken Appointment Fee: Your appointment time is reserved for you alone, and without adequate notice in advance, we are unable to make use of the missed appointment time. A fee of $150 too is charged for appointments missed or broken with less than business days advance notice. Our business days consist of Tues-Fri. Therefore, as an example, a Tuesday at 8:00 am appointment must be canceled by the prior Thursday at 8:00 am to avoid a charge. I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, I agree to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release the information necessary to secure payment. PATIENT INITIALS Patient Name Date MM slash DD slash YYYY Person Responsible for the amount Signature of Parent/GuardianACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I do hereby acknowledge receipt of a copy of the Notice of Privacy Practices, Policies, and Procedures.Printed Patient Name Signature of patient/parent/guardianDate MM slash DD slash YYYY If and only if this form is signed by Parent/Guardian,Please also print name here If and only if this form is signed by a Personal Representative for the patient, please complete the followingSignature of Personal RepresentativeDate MM slash DD slash YYYY Legal Authority of Personal Representative NOTICE OF PRIVACY PRACTICESEffective Date MM slash DD slash YYYY 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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.CONTACT INFORMATION For more information about our privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact our Privacy OfficeTitle PhoneFaxEmail Address OUR LEGAL DUTYWe are required by law to protect the privacy of your protected health information ("medical information"). We are also required to send you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on the date set forth at the top of this page and will remain in effect unless 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 any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, including medical information, we created or received before we made the change.We may amend the terms of this notice at any time. If we make a material change to our policy practices, we will provide to you the revised notice. Any revised notice will be effective for all health information that we maintain. The effective date of a revised notice will be revised. A copy of the current notice in effect will be available in our facility and on our website if applicable. You may request a copy of the current notice at any time. We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our patients' medical information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse.USES AND DISCLOSURES OF YOUR MEDICAL INFORMATIONTreatment: We may disclose your medical information, without your prior approval, to another dentist, a physician, or other health care provider working in our facility or otherwise providing you treatment for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed. Payment: We provide dental service & your medical information may be used to seek payment from your insurance plan. For example, your insurance plan may request and receive information on dates that you received services at our facility in order to allow your employer to verify and process your insurance claim. Health Care Operations: We may use and disclose your medical information, without your prior approval for health care operations. Health care operations include: healthcare quality assessment and improvement activities; • reviewing and evaluating dental care provider performance, qualifications, and competence, health care training programs, provider accreditation, certification, licensing, and credentialing activities; • conducting or arranging for medical reviews, audits. and legal service, including fraud and abuse detection and prevention: and business planning, development, management, and general administration, including customer service, complaint resolutions and billing, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research. We may disclose your medical information to another dental or medical provider or to your health plan subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the medical information is for that provider's or pian's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention. Your Authorization: You for your legal personal representative) may give us written authorization to use your medical information or to disclose it to anyone for any purpose. Once you give us the authorization to release your medical information. we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writing, except if we have already acted based on your authorization. Your 'evocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice. We will obtain your authorization prior to using your medical information for marketing, fundraising purposes, or for commercial use. Once authorized. you may opt out of any of these communications. Family, Friends, and Others Involved in Your Care or Payment for Care: We may disclose your medical information to a family member, friend or any other person you involve in your care or payment for your health care. We will disclose only the medical information that is relevant to the person's involvement. We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify. a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts We will provide you with an opportunity to object to these disclosures unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances. Health-Related Products and Services: We may use your medical information to communicate with you about health-related products, benefits, services. easier for those products and services. and treatment alternatives. Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders. Plan Sponsors: If your dental insurance coverage is through an employer's sponsored group dental plan, we may share summary health information with the plan sponsor.Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, when required by law. and when authorized by law for the following kinds of public health and public benefit activities: • for public health, including to report disease and vital statistics. child abuse, and adult abuse. neglect or domestic violence; • to avert a serious and imminent threat to health or safety; • for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, anti-fraud prevention agencies; • for research: • in response to court and administrative orders and other lawful processes; • to law enforcement officials with regard to coming victims and criminal activities; • to coroners, medical examiners, funeral directors, and organ procurement organizations. • to the military, to federal officials for lawful intelligence. counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; end • as authorized by state worker's compensation laws. If a use or disclosure of health information described above in this notice re prohibited or materially limited by other laws that apply to us. it is our intent to meet the requirements of the more stringent law. Business Associates: We may disclose your medical information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy at your information and are not allowed to use or disclose any information other than as specified in our contract. Data Breach Notification Purposes: We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information. Additional Restrictions on Use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of Getten health information, including highly confidential information about you. "Highly confidential information" may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information: 1. HIWAICS 2. Mental health 3. Genetic tests 4. Alcohol and drug abuse 5. Sexually transmitted diseases and reproductive health information6. Child or adult abuse or neglect, including sexual assault YOUR RIGHTSAccess: You have the right to examine and to receive a copy of your medical information, with limited exceptions. We will use the format you request unless we cannot practicably do so. You should submit your request in writing to our Privacy Officer. We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of the medical information you request. Contact our Privacy Officer for information about our fees. Disclosure Accounting: You have the right to a list of instances in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you. and for certain other activities. You should submit your request to our Privacy Officer. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request. Amendment: You have the right to request that we amend your medical information. You should submit your request in writing to our Privacy Officer. We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we deny your request, you may have a statement of your disagreement added to your medical information. If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.Restriction: You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. Except in limited circumstances. we are not required to agree to your request. But if we do agree, we will abide by OUR agreement, except in a medical emergency or as required or authorized by law. You should submit your request to our Privacy Officer. Except as otherwise required by law, we must agree to a restriction request if: 1. except as otherwise required by law, the disclosure is to a healthy, plan for purposes of carrying out payment or health care operations and not for purposes of carrying out the, augmented and 2. the medical information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full by the patient. Confidential Communication: You have the right to request that we communicate with you about your medical information in confidence by means or to locations that you specify. You should submit your request in writing to our Privacy Officer. Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. A breach may be delayed or not provided if so required by a law enforcement official. You may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if we know the identity and address of such individual(s). Electronic Notice: If you receive this notice on our website or by electronic mail; e-mail), you are entitled to receive this notice ire written form. Please contact CV Privacy Officer to obtain this notice in written form.COMPLAINTSIf you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, about your medical information, about restricting our use or disclosure of information, or about how we communicate with you about your medical information (including a breach notice communication), you may contact to our Privacy Officer.You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for civil Rights' Hotline at 1-800-368-1019. We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to tile a complaint with us or with the U.S. Department of Healte and Human Services,CAPTCHACommentsThis field is for validation purposes and should be left unchanged.