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Family Tree Dentistry

26415 Carl Boyer Drive; Suite 200,
Santa Clarita, CA 91350

WELCOME( * mandatory to fill )

We are pleased that you have chosen Sarah J. Phillips. D.D.S and our dental team to provide you with the attention, care and technology necessary for optimum oral health. We are concerned about your immediate dental needs as well as preventing oral disease in the future. 

We invite you to become the key to your success. Our office will provide you with the most ideal treatment plan and advice available today. We are committed to educating our patients on the "How-to's" of good home care, and we will provide you with information on the latest materials and techniques appropriate for your special needs. 

We welcome you to join us as part of the team. Our office takes pride in our high standards of infection control and sterilization procedures. If you would like more information on our specific steps towards the maintenance of a clean and safe dental office. please let us know. 

Dr. Phillips enjoys working closely with a committed staff and refers to dental specialists if necessary. Our office sees patients of all ages. and we have emergency dental services available. 

For your convenience we have provided with this welcome letter, our office policies, patient registration, patient health history and HIPPA policies. As we are an environmentally conscious office. Please print and fill out the fill in the blank- and "signature required" necessary following if current dental x-rays are available, we would appreciate having those as part of your records. 

We  will provide an estimate  of your out of pocket expenses at your request. If any financial arrangements is needed the should be arranged prior to initiating restorative procedures. 

We are looking forward to getting to know you, your family and friends. If you have any questions feel free to contact our office. Take a moment to view our website at where you will find additional information regarding our office and staff. We are looking forward to meeting you! 


Sarah J. Phillips, DOS 

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  •  Policy Holder
  •  Responsible Party
  •  Responsible party is also a policy holder for patient
  •  Primary Insurance Policy Holder
  •  Secondary Insurance Policy Holder
PATIENT INFORMATION( * mandatory to fill )

Responsible Party (If other than Patient)




INSURANCE DETAILS( * mandatory to fill )

Primary Insurance Information

Secondary Insurance Information

OFFICE POLICY( * mandatory to fill )

Please read this page thoroughly. It describes our office policies regarding financial arrangements and missed appointments. 

As a courtesy to our patients we confirm appointments via text or email. Please initial to accept this method of communication. 


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We know it is difficult and time consuming trying to read your policy book that your insurance company provided you. As a special bonus for you, we subscribe to a service which updates dental insurance benefits by employer and policy number for the year. Our staff also telephones your insurance company prior to your visit in order to verify benefits. With this information, we can estimate very closely what your patient portion would be for the procedures you might need. Occasionally, the insurance representative on the phone and/or our computer information is incorrect. That is why we estimate patient portions rather than quote them as definite. Your 

your portion of each visit, We accept cash, checks, credit cards and ATM cards which are linked to Mastercard and Visa. Please be aware that during treatment, it may be necessary to change or add procedures. We will make every effort to advise you of these changes as they may occur. 

We do not finance our patients' dental care; however we do offer 3rd party financing with CareCredit. This is like a healthcare credit card used by many health professionals, where in most cases, the doctor pays your interest for you so you can get your treatment done as soon as possible. Any balances on your account are subject to a finance charge after 30 days. 

 We make every effort to stay right on time with our schedule. Your time is very important to us! For best customer service, we schedule time with one patient and do not double book. We need your cooperation in helping to keep  everyone's appointments at their correct times by being on time to your scheduled appointment and calling us if you are running late. When an appointment is missed without 24 hours' notification. you will be charged a fee of $ 75.

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Twenty-four hours is the minimum amount of time we need to make arrangements to allow someone else to use that time. We do leave telephone/email messages for you if you wish us to remind you of your appointments, but it is ultimately your responsibility to remember the appointments you have scheduled with us. 

If you have any questions about anything described here, please call us. We are always happy to clarify anything regarding your treatment, financial obligations, scheduling, etc. Again, thank you for choosing our office. This policy note is to prevent any miscommunications that may arise. We look forward to providing you with great customer service and giving you a smile you love! 

I have read and understand these office policies. 


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HIPAA POLICY( * mandatory to fill )


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. 


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; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids 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 vision 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. 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 these reasons, we will ask you for special written 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; 

- USE'S 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 eye care. 


We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call 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 mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. 


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.


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 or fax 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 or fax 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 will 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 or fax 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 or fax 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. 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 or fax 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 or fax shown at the beginning of this Notice. 


By 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 and have copies available in our office. 


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 or fax shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone. 


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. 

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I read and acknowledge the attached Notice of Privacy Practices of Sarah J Phillips D.D.S.

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FINANCIAL AGREEMENT( * mandatory to fill )

As a courtesy to our patients we gladly process your insurance claim. We will estimate as closely as possible to your coverage, however until we actually receive payment form the insurance, it is just an estimate. With so many insurance options available it is impossible for our staff to know what every policy covers. Consequently, you as the patient need to know the exclusions and limitations of your policy and to inform the staff of those limitations.

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* Payment for all services is due at the time the service is rendered.

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* Patient/ or responsible party is accountable for knowledge and commitment of their insurance plan responsibilities. (i.e keeping track of your annual benefit maximum, applied alternate benefit codes downgrades, deductibles and all other frequencies, limitations or exclusions.

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* Responsible parties will receive an invoice for any unpaid balances after insurance claims close.

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* Patient understands that the treatment plan is only an estimate and subject to modification depending on unforeseen circumstances that may arise during the course of treatment.

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* If either you or the carrier, during the course of the treatment, terminate or change your insurance coverage, you are responsible for any unpaid portion of the expense.

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* 24 hr notice is required for cancellation of appointments. We reserve the right to charge a $75 fee for a failed appointment or ones that are not cancelled within the 24hr time frame. If repeated no-shows occur, you will be given 30 days emergency dental care and then discharged from care.

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 Cash , Personal Check, Visa, MasterCard, Discover, Flexible spending accounts, Care Credit , Private Savings Plan.

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