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Honest Teeth Dentistry

15255 Watertown Plank Rd suite 100,
Elm Grove, WI, 53122
2627847770

Patient Details( * mandatory to fill )
  •  Email
  •  Home Phone
  •  Cell Phone
  •  Work Phone
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Emergency Contact

  •  Self
  •  Other

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Dental Insurance Information

Primary

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  •  No
SECONDARY INSURANCE INFORMATION( * mandatory to fill )
Dental History( * mandatory to fill )
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Have you ever had

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Check all that apply

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MEDICAL HISTORY( * mandatory to fill )
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Women Only

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MEDICAL HISTORY( * mandatory to fill )

Medications

Allergies

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Do you currently have, or have you ever had, any of the following conditions?

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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients) health. It is my responsibility to inform Honest Teeth Dentistry of any changes in medical status.

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Honest Teeth Dentistry Office and Financial Policy( * mandatory to fill )

Thank you so much for choosing Honest Teeth Dentistry for your oral health needs! We are looking forward to working with you to meet your oral health goals by providing you with the tools, education and treatments to help promote overall wellness in your life. Before we get started, please review the below office policy to make sure we all have a healthy relationship and good experiences moving forward.

Appointment/Reservation Cancellations: Our dental team loves helping patients and our patients love coming to see us! When you make an appointment we reserve time, space and a provider especially for you. Should you have an emergency requiring you to move an appointment, please let us know as soon as possible! That allows us time to provide care to someone else who really needs it.

Cancellation/No-show fees: We understand that sometimes things come up last minute and we are happy to work with you on those to get your care rescheduled ASAP. Should a patient have more than one cancellation with less than 2 business days advance notice in a 12 month period, you agree to pay a $45 fee for hygiene/cleaning visits and/or a $90 fee for doctor visits. Each additional no show appointment will come with an additional, appropriate charge.

Minor patients and appointments: Patients under the age of 18 or anyone with an appointed guardian/power of attorney must arrive for their dental appointments with a guardian present for the entirety of their treatment or appropriate consent forms must be signed and returned to the office prior to the appointment time. Payment is due at the time of service for all patients, so please make arrangements for payment in advance.

Dental Benefits ["Insurance"]: We are happy to work with you and your dental benefit provider in the capacity that we will submit all necessary paperwork on your behalf. Your dental benefit provider is a for-profit company and not your friend or fiduciary. Please recognize that your dental benefit provider has a vested interest in you paying your premiums each month and the company's shareholders are much happier not paying for any of your services. You are ultimately responsible for paying for the services you choose to have completed. After 30 days of attempts for reimbursement from your dental benefit company we will bill you for the full amount and supply you with any necessary clinical documentation to submit for payment. After 60 days of non-payment you will have a monthly finance charge of 1.5% applied to your account. Honest Teeth Dentistry is not responsible for changes to your dental benefit plan that you or your employer may have changed, renegotiated or otherwise altered in between visits. We will make every effort to work with you to maximize the benefits you recieve from your dental benefit provider but ultimately the person who has entered into the contract with the dental benefit provider is you. Please provide us with any updated dental benefit information before your appointment so our team can help you minimize headaches associated with utilizing dental benefits.

Payment for services rendered: Payment is due at the time of service unless written payment arrangements are made with the financial coordinator in advance. For your convenience we accept Visa/Mastercard and also offer patient financing which can offer low interest payments made over time. Our office can extend a 5% discount to patients who do not utilize dental benefit coverage and who pay in full via cash or check on the day of service.

Amalgam or Silver Filling Material: Regardless of what your insurance company will cover, we only place resin ("tooth colored") fillings. Placing amalgam ("silver") fillings may cause a health risk to the providers who handle the material frequently. Due to that risk, Honest Teeth will not place silver type fillings. Silver and tooth colored fillings have similar wear, longevity, and survival properties and are a safer alternative for our team.

I,

Have read, agree to, and understand fully the office policies of Honest Teeth Dentistry.

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HIPAA 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 PROTECTED HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This notice takes effect September 23, 2013, 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 the changes in our privacy practices and the new terms of our Notice effective for all protected health information that we maintain, including protected 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 PROTECTED HEALTH INFORMATION
We use and disclose protected health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use and disclose your protected health information to a dentist, hygienist or other healthcare provider for treatment purposes.

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

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

Authorization: In addition to our use and disclosure of your protected health information for treatment, payment or healthcare operations, you may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You may revoke such authorization at any time by written request, but we cannot take back any uses or disclosures already made with your permission. Unless you give us a written authorization, we cannot use or disclose your protected health information for any reason except those described in this Notice. 

To Your Family and Friends: We may disclose protected health information about you to your family members or friends if we obtain your verbal authorization to do so or if we give you an opportunity to object and you do not object. We also may disclose protected health information to your family or friends if we can infer from the circumstances, based on our reasonable judgment, that you would not object, for example when you bring your spouse with you when treatment is discussed. We may use our professional judgment to infer that it is in your best interest to allow another person to pick-up filled prescriptions, medical supplies, x-rays or recommend that they take you to your physician or emergency room.

We may use or disclose protected 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, or your general condition. If you are present, then prior to use or disclosure of your protected 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 protected health information based on a determination using our professional judgment, disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare. 

 

Marketing Health-Related Services: We may use or disclose your protected health information for marketing purposes with your written authorization. 

Required by Law: We may use or disclose your protected health information when we are required to do so by federal, state or local law or legal process, for example, subpoena, court order, administrative order, warrant, or summons; and pursuant to workers’ compensation laws. 

Abuse or Neglect: We may disclose your protected 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 protected health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 

Governmental Officials and Law Enforcement: We may disclose to authorized governmental officials protected health information required for lawful investigation, military authorities, the protected health information of Armed Forces personnel, and a correctional institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances. 

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as postcards, voicemail message, or letters) or information about oral health care, and related benefits and services.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You must request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies, postage and staff time. If you request an alternative format that we can practicably provide, we will charge a cost-based fee for providing your protected health information in that format. If you prefer, we will prepare a summary or an explanation of your protected health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fees.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected 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. 

Restriction: You have the right to request in writing that we place additional restrictions on our use or disclosure of your protected 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). We are required to agree to requests that we not disclose protected health information to your health plan with respect to services for which you have paid out of pocket in full.

Alternative Communication: You have the right to request that we communicate with you about your protected 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 protected 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.

Breach Notification: You have the right to receive notice if the security of your unsecured protected health information is breached.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive a paper copy of this Notice upon request.

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 protected health information or in response to a request you made to amend or restrict the use or disclosure of your protected health information or to have us communicate with you by alternative means or at alternative locations, you may submit a complaint 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 protected health information. You will not be penalized in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

 

 

I have received a copy of this offices notice of privacy practices.

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