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Patient Registration Paperwork

Tender Care Dentistry

29795 Three Notch Rd,
Charlotte Hall, MD 20622
3012900001

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Authorization to Release XRays( * mandatory to fill )

I authorize Tender Care Dentistry to email the above-mentioned patient's x-rays directly to another dental office for any of the following reasons:

In the event, Tender Care Dentistry should refer my child to another dental office or specialist for a consultation and/or treatment.

In the event, I choose to transfer my child to another dental office for a consultation and/or treatment.

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Authorization to Treat( * mandatory to fill )

In the event, I am unable to accompany my child to his/her dental appointment I authorize the following person/persons to approve authorization for treatment.

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HIPAA NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

Federal protections for the privacy of health information and personal information is in effect. The HIPAA Notice of Privacy Practices for this dental office is available at the front desk when requested. Your signature below indicates that you are acknowledging notification of the privacy practices of this office.

Acknowledgment of Privacy Rules

ARBITRATION AGREEMENT

This dental practice agrees to provide to the undersigned patient dental health care services in consideration for the payment received. By signing this arbitration clause you are agreeing to have an issue of dental malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. The arbitration agreement you are accepting is available at the front desk when requested.

  •  I have read the material available at the front desk.
  •  I would like to request a printed copy to take with me

CHILD OR MINOR SOCIAL MEDIA AUTHORIZATION

At Fusion, we strive to create a family environment for our patients. We regularly interact with our patients and community through social media. We need your written consent if you would like us to include your child or children in our cool online updates.

  •  You may use my child's first name & photo on your Web site gallery and social media pages. This may include Facebook, Google+, Twitter, Instagram, and Pinterest.
  •  You may use my child's photo as referenced above, but no name.
  •  I would prefer that my child's smile is not featured online.
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Missed Appointment Policy( * mandatory to fill )

Dear Parents and Guardians,

Our goal is to improve the lives of those we serve. We accomplish this as we deliver high-quality, personalized care to our patients. We treat you as more than just a number, always keeping your best interests in mind. Dental care requires periodic and follow up care to ensure good oral health. Your Dentist only schedules an appointment when it is dentally required for your benefit. Repeated failure to keep appointments prohibits us from delivering care to you and to other patients. As a result, we have established a missed appointment policy that will allow us to meet our goals for you.

We recognize that emergencies arise that may keep you from making or canceling your appointment in a timely manner so our policy has three (3) levels. A "missed appointment" is when a patient fails to keep an appointment and also fails to cancel the appointment. If you must cancel your appointment, we ask that you call twenty-four (24) hours in advance or as soon as possible. This will keep you from having a missed appointment on record.

The first three (3) times will result in letters reminding the patient of the missed appointments. Upon the third missed appointment, the patient will receive a letter notifying them that they are discharged from our practice.

We thank you for trusting us with your dental care and assisting us in delivering the best care possible. If you have any questions regarding this policy, please ask and we will be happy to answer them.

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Notice of Privacy Practices( * mandatory to fill )

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.

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 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.

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 another person to the extent necessary to help 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 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 the 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 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 using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.)

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. 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.

Restrictions: 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 alternative 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 our 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 have questions or concerns, please contact us.

If you are concerned 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 alternative 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.

Acknowledgment: I, hereby acknowledge that I have read and fully understand the contents of this document, and I have been given the opportunity to ask any and all questions.
**You may refuse to sign this acknowledgment.

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Office and Financial Policies( * mandatory to fill )

Please read carefully and sign to acknowledge understanding and agreement

Welcome to Tender Care Dentistry. We are excited to be involved in the partnership that will pave the way to your child’s healthy and beautiful smile.  So that we may work together towards this goal we hope that you will take the time to read and understand our office policies.

CONFIRMATION POLICY

You MUST confirm your appointment by 3 pm the day before your scheduled appointment.  If appointed on a Monday you must confirm by 3 pm the Thursday before. Failure to confirm will result in forfeiting your appointment time.  Confirmations can be done via text, email or phone call.                                                                         

CANCELATION POLICY

To give you and your child the high-quality service you deserve it will be necessary to keep all scheduled appointments.  If you absolutely cannot keep the appointment it will be mandatory for you to notify us within 24 hours of your appointment.                         

CELL PHONE POLICY

The use of cell phones and other handheld devices are extremely disruptive. The use of Cell phones is prohibited outside of the waiting room area.                               

FOOD AND DRINK POLICY

Eating or drinking within the dental office is prohibited.  For safety reasons, OSHA prohibits any food or drink to be consumed in the clinical areas.

FINANCIAL POLICY

All co-pays and deductibles are due at the time services are rendered unless special arrangements are made.

We accept cash, check, Visa, MasterCard, Discover, and CareCredit.                                                                                                       
Primary Insurance:  As a courtesy, Tender Care Dentistry will file the primary insurance claim for you.  Our helpful staff will attempt to ESTIMATE your insurance benefits as accurately as possible.  However, changes in benefits and exclusions unique to your policy may result in a refund or balance due after your insurance has paid. Please be familiar with your insurance benefits to help us with this process. 

Please remember that your insurance policy is a contract between you and your insurance company; we are not a party to that contract nor are we responsible for procedures that are not covered for any reason.  We must have complete and up to date insurance information to bill your insurance company on your behalf.  If your insurance company has not paid their portion within 60 days the balance will become your responsibility.                                                 
Secondary Insurance:  Tender Care Dentistry will no longer file any secondary claims unless you are primarily covered by the Federal Blue Cross Blue Shield plan or if your secondary insurance is through the Maryland Medical Assistance Program.

Returned Checks:  All checks are electronically deposited in real-time on the day they are written.  A $35 fee will be applied to any returned checks.

Unpaid Accounts:  Any account 90 days past due may be sent to a collection agency or settled in small claims court.  In these events, you will be responsible for any collection and/or court fees incurred.

By signing below I assume financial responsibility as stated above.  I also assume responsibility for all collection and legal fees if my account becomes past due.


I have read, understand, and agree to the financial policy.

Credit Card Signature Authorization:  Signing this section will enable you to make credit card payments over the phone to pay on your account at Tender Care Dentistry. Without a valid signature on file, we will be unable to process credit card payments via telephone.

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