Patient Registration Form Patient Details

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Patient Registration Form Contact Information

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Patient Registration Form Mothers Information

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  •  Guardian
  •  Stepmother

Patient Registration Form Fathers Information

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  •  Guardian
  •  Stepfather

Patient Registration Form Person Responsible for Account

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Patient Registration Form Primary Insurance

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Patient Registration Form secondary insurance

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Patient Registration Form Medical History

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Does your child have a history of any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Patient Registration Form dental history

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  •  Cavity
  •  Teeth Cleaning
  •  Tooth Extraction
  •  Toothache
  •  Dental X-ray
  •  Prolonged bleeding after extraction
  •  Gum Swelling
  •  Local Anesthesia
  •  Braces (Orthodontic Treatment)
  •  Injury to Teeth/Face
  •  Filling (s)
  •  Other
  •  Yes
  •  No
  •  Thumb/Finger Sucking
  •  Pacifier
  •  Use Toothpaste with Fluoride
  •  Adult Assisting
  •  Floss
  •  Fluoride Supplement
  •  Sugary/Starchy snacks more than 3/day
  •  Frequent Juice/Sports/Soft Drinks
  •  Bottle Fed
  •  Baby Bottle at Bedtime
  •  Breast Fed
  •  Yes
  •  No

By signing here, I certify that I have completed the requested information on this form to the best of my knowledge:

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Patient Registration Form financial policy

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Welcome to Frontier Kids Dentistry , the office of Dr. Shane Jenks. Please feel free to ask any questions you may have regarding this form or any other aspect of your child’s appointment.

Our Policy requires payment at the time of service for your visit.

If the patient does not have dental insurance, payment in full is expected on the day of service, unless other arrangements have been previously made.

If you are a member of a medical Insurance Plan and have chosen us as a provider of your care, you are responsible to:

* Provide us with information relative to your claim, including insurance card, number, employer, birth date, and address and Social Security number. This information is requested on the Patient Registration form, which we ask that you complete during your initial or subsequent visit.

* Pay your deductible and/or coinsurance at the time of service.

* Pay for services not covered by your insurance carrier.

Insurance claims for your carriers are filed as a courtesy at no charge to you.

* To assist you with your payment, our office accepts Cash, Care Credit, Cashiers Checks, Money Orders, Travelers Checks, Visa, Mastercard, Discover, and American Express.

* Personal checks are accepted with proper identification (driver's license or photo ID). A $30.00 returned check fee will be added to returned checks plus applicable bank charges.

* Care Credit is a convenient, low minimum monthly payment with no interest, program for your entire family designed to pay for healthcare not covered by insurance. Visit www.carecredit.com

* When your bill is unpaid, a collection agency may be chosen to manage delinquent accounts. If your account is placed with a collection agency, you will be responsible for all costs of collection. Services are rendered to the patient and not to an insurance company, therefore the person responsible for the account is responsible to Frontier Kids Dentistry for payment.

Cancellation Policy

* We require a 24 hour cancellation notice for a scheduled appointment.

* Patients who fail to show for their scheduled appointment without giving due notice will be charged a $40.00 fee. This is not payable by your insurance.

I have read and fully understand my financial responsibilities under this policy.

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Patient Registration Form Notice of Privacy Practices

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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect August 15, 2019, 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 changes in our privacy practices with any new terms of our Notice, effective for all health information that we maintain; including health information we created or received before we made any change. Before we make a significant change in our privacy practices, we will amend 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 beginning of this notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

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

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

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

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

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

Persons Involved In Care: We must disclose your health information to you as described in the Patient Rights section of this Notice. Under certain circumstances, we may disclose health information to family members, other relatives, or close personal friends or others that you identify, to the extent it is directly relevant to their involvement with your care or payment related to your care; or to notify them of your location, general condition, or death. If you are present, you may object to such uses or disclosures. However, in the event of your incapacity or emergency situation, we will disclose health information based upon a determination using our professional judgment and our experience with common practice to make reasonable inferences of your best interest.

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

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

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

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 (via telephone, telephone answering machine, voicemail, email or letter).

PATIENT RIGHTS

Access: 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 contacting our office directly or by sending us a letter to the address at the top of this notice. We may charge you a reasonable cost based fee for expenses such as copies, staff time and postage. If you request an alternative format, we will assess a costbased fee for providing your healthcare in that format.

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 six years, but not before April 14, 2003. You are entitled to one such list per year without charge. Additional requests may be subject to a costbased fee.

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 situation). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or locations. Your request must be made in writing and 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.

Additional Notice Copies: Regardless of whether you received this Notice electronically or in paper form; you are entitled to additional paper copies (via written request).

QUESTION AND/OR COMPLAINTS

If you want more information about our privacy practices or have a question and/or concern, please contact us.

If you are concerned that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services (address provided, upon request). We will not retaliate in any way if you choose to file a complaint.

We support your right to the privacy of your health information.

Patient Registration Form Patient Acknowledgement and Consent Form

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Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.
To comply with one of HIPAA's requirements, we are giving you a copy of our Notice of Privacy Practices. This notice of Privacy Practices contains the information that HIPPA requires us to disclose regarding our privacy practices.
Existing Missouri Law requires (in addition to our attempt to obtain your written acknowledgment, discusse  above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with a defense to a claim challenging our professional competence; a review entity's functions; a claim for payment of fees; a third party payer's examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.
From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading "acknowledgement" to acknowledge that you have today received a copy of our notice of privacy practices.

I acknowledge that I have today received a copy of the Notice of Privacy Practices.

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