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Patient Registration Form

Tualatin Dental Care

8375 SW Warm Springs St,
Tualatin, OR 97062
(503) 885-8899

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

I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of Information concerning my (or my child's) health care, advice, and treatment to another dentist, or for evaluating and administering any claims for Insurance benefits. I consent to the direct payment of my Insurance benefits to dentist or dental group and understand that my Insurance benefits may pay less than the actual bill for services and that i am responsible for any services not paid or covered by my Insurance benefits and any account balance.

ELECTRONIC COMMUNICATIONS. I consent to receiving HIPAA-compilant electronic communications, such as email and text messages regarding treatment, payment and health care operations. I understand that there is no obligation to receive those electronic communications. Message/data rates may apply, and I may opt-out of receiving electronic communications at any time by clicking the unsubscribe link provided in emails, or by replying STOP via text to 98269. Gn to www.greatexpressions.com for more information. 

I attest to the accuracy of the information on this page. 

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Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
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  •  Local anesthetics
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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 parent's) health. It is my responsibility to inform the dental office of any changes in medical status.

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PATIENT RECORD OF DISCLOSURES ( * mandatory to fill )

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the Individual's office instead of the individual's home, 

I wish to be contacted in the following manner (check all that apply): 

  •  OK to leave message with detailed information
  •  Leave message with call-back number only
  •  O.K. to mail to my home address
  •  OK to mail to my work/office address
  •  O.K. to fax to this number
  •  OK, to leave message with detailed information
  •  Leave message with call-back number only
  •  Other
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The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual,

Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record. 

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

Record of Disclosures of Protected Health Information

(1) Check this box if the disclosure is authorized

(2) Type key: T=Treatment Records; P=Payment Information; O=Healthcare Operations

(3) Enter how disclosure was made; F=Fax; P=Phone; M=Mail; O=Other

Financial and Appointment Agreement( * mandatory to fill )

It is our mission at Tualatin Dental Care to continue to put our patients first, make your experience positive and maintain a lasting relationship that keeps you and your family healthy. Thank you for allowing us to share our Financial and Appointment Agreement with you. Please let us know if you have any questions.

We strive to provide high-quality dental care and also work to avail to the financial options that make dentistry affordable for you and your family. We offer:

  1. Acceptance of Visa, Master Card and Discover
  2. Care Credit
  3. We have a Preferred Provider office for many dental plans which afford you a discounted fee based on your particular plan.
  4. We offer our private In-House Dental Plan 

Please Read and Sign Below: 

Payment for any service you receive from Tualatin Dental Care is your responsibility. We will submit services to your insurance company, but please note that full payment, even for children of divorced parents, third party claims (legal action or motor vehicle accident), and/or insurance disputes, is the responsibility of the person signing below. Cash accounts are due on the date of service, Uncomplicated insurance claims are due within 60 days from the date of service. 

As a courtesy, we will bill your insurance carrier. We will send you a monthly statement to keep you informed of your claim status. However, if we are unable to bill the insurance carrier due to timeliness of receiving updated carrier claim information or not able to negotiate disputed claims or claims with dual insurance that become protracted, payment is due 75 days from the date of service.

Your Patient Portion is due at the time of service. We work very hard for our patients to determine their level of benefits and the patient portion due at each appointment. We base our estimated from the information provided to us by your insurance carrier. There are times when this information is NOT accurate. Therefore, your estimated portion is just that, an estimate. If you pay by check and your check is returned for insufficient funds there is a $25 Non-Sufficient Funds fee added to your account, in addition to the amount of the check. 

Delinquent accounts are assigned to a reporting collection agency. We make reasonable attempts to contact you and work with you. If it becomes necessary to effect collections, you agree to pay for all costs and expenses, including reasonable attorney's fees.

Appointment Agreement. We make every effort to value your time and appointments are reserved specifically for you. We are committed to your oral health and keeping your scheduled appointments allows us to be partners in your dental care. If you have a conflict in your schedule and are unable to keep an appointment, we truly appreciate your courtesy of providing us 48 to 24-hour notice to avoid a $50 fee per hour of a scheduled appointment. If you have two missed appointments in the 12-month span, you may be required to make a treatment deposit when scheduling the next appointment. Keeping the appointment will ensure that the deposit will be applied to the treatment. However, if you fail to keep the appointment, the deposit is nonrefundable.

By signing below, you understand that you are fully responsible for the total payment of all procedures performed by Tualatin Dental Care This includes any treatment that is not a benefit of your dental plan. If for any reason, the estimated amount is not paid by your dental plan, it becomes your obligation. 

* I acknowledge and appointment reservation

* I agree to provide a minimum of 48-24 hours notice if I need to change my appointment for any reason.

* If I miss 2 appointments without the required 48-24 hours notice in a 12-month span, 1 acknowledge I may be required to leave a deposit at the time of scheduling in order to be appointed. 

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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 CONTENT 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 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 other 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 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. 

Acknowledgement: 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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Hipaa Information( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I,

on this date

do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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