smiles4children - Eldersburg - New Patient Packet

Date

MonthDayYear
Date

Child's Name*

First NameMiddle NameLast NameNickname (if any)
Date of Birth*

MonthDayYear
Age*
Sex:*

MaleFemale
School (Please type N/A if it does not apply)*
Grade*
Address*

Home Address

Street Address Line 2

CityState

Zip
Name and Age of Siblings (Please type "N/A" if it does not apply)*
Interests or hobbies*

Parent's Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Parent 1*

First NameLast Name
Social Security #
DOB*

MonthDayYear
Cell Phone #*
Please enter a valid phone number.
Home/Alternate Phone #
Please enter a valid phone number.
Email*
example@example.com
Address*

Home Address

Street Address Line 2

CityState

Zip
Employer (Please type "N/A" if it does not apply)*
Occupation (Please type "N/A" if it does not apply)*
Address

Business Address

Street Address Line 2

CityState

Zip
Parent 2 Name*

First NameLast Name
Social Security #
DOB

MonthDayYear
Home Phone #
Please enter a valid phone number.
Cell Phone #
Please enter a valid phone number.
Email
example@example.com
Address

Home Address

Street Address Line 2

CityState

Zip
Employer
Occupation
Address

Business Address

Street Address Line 2

CityState

Zip
Whom May We Thank for Referring You?*
Ex: John Smith, Google, Insurance, Facebook, etc.

Primary Dental Coverage
Does the child have primary dental coverage?*
Subscriber (covered employee)
Employer providing insurance
Name of insurance carrier (company)
Subscriber/Member ID #
Group/Policy #
Take Photo of Dental Insurance Card
Secondary Dental Coverage
Does the child have secondary dental coverage?*
Subscriber (covered employee)
Employer providing insurance
Name of insurance carrier (company)
Subscriber/Member ID #
Group/Policy #
Medical Insurance Coverage
Subscriber (covered employee)
Employer providing insurance
Name of insurance carrier (company)
Subscriber/Member ID #
Group/Policy #

Child's Physician (Please include first and last name)*
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of last physical examination?*

MonthDayYear
Results
Is a physician currently treating your child for a specific illness?*

YesNo
If so, for what reason?

0/100
Is your child taking any medication?*

YesNo

Has your child shown any allergies or unusual reactions?
A) Medications or drugs*
Please list all medication/drug allergies
B) Food*
Please list all food allergies
C) Other*
Please list other allergies
Were there any problems with the pregnancy?*

YesNo
If yes, please explain
Did your child go home with the mother from the hospital?*

YesNo
If no, please explain
Has your child ever been hospitalized?*

YesNo
If so, when?
For what reason?
Has your child had any operations?*

YesNo
If so, when?
For what reason?
Are there any psychological or emotional problems you would like to bring to our attention?*

YesNo
If so, please explain
Does your child have a history of the following diseases or conditions? Please check all that apply.

Accidents or Severe InfectionsADD/ADHDAIDS or AIDS Related Symptoms, HIV+Anemia or Blood DisordersAsthma or Lung Problems AutismAutismBleeding ProblemsBlood TransfusionsCerebral PalsyConvulsion, Seizures, or EpilepsyDevelopmental DelayDiabetesHeadachesHeart Murmur, Congenital Heart DiseaseIntellectual DisabilityKidney or Bladder ProblemsLiver Problems, Jaundice or Hepatitis MalignanciesMalignanciesSpeech, Learning, or Hearing DisorderVision ProblemsOther
PLEASE DESCRIBE ANY CURRENT MEDICAL TREATMENT INCLUDING DRUGS, PENDING SURGERY, RECENT INJURIES OR ANY OTHER INFORMATION DENTIST SHOULD BE AWARE OR THAT HAS NOT BEEN COVERED ABOVE. (Please type "N/A" if it does not apply)*

0/100

FINANCIAL AGREEMENT

Thank you for choosing smiles4children for your child’s dental care.

The following is a statement of our financial agreement. Please read and sign. Smiles4children reserves the right to change this financial policy at any time. A current financial policy will always be available upon request.
- Payment is due in full at the time of service.
- We accept Cash, Checks, Visa, MasterCard, Discover, American Express & Care Credit.
- Online Bill Pay is available through our website www.smiles4children.net
Dental insurance
- Your dental insurance policy is an agreement between you and your insurance company. Please familiarize yourself with your benefits as any amount not covered by your insurance company is payable by you at the time services are rendered. These fees include deductibles, co-payments, or certain procedures not covered or partially covered by your insurance policy.
- If we have received all of your insurance information on the day of the appointment, we will submit the claim as a courtesy to you. If this information is not available you will be responsible for fees the day of service.
- Once your insurance company has responded to your claim, any balance is now your financial responsibility. This will be billed to you and payment is due within 30 days.
- If your insurance company does not pay for your child’s services within 45 days of treatment, you are responsible for full payment.
Appointment information
- If you cannot keep your scheduled appointment we ask for at least 24 hours or one full business day notice. Please notify us during business hours. A $68.00 per appointment fee will be charged for a failed appointment or an appointment that is cancelled less than 24 hours in advance. Multiple failed appointments will result in discharge from our care.
Past due accounts
- Accounts are considered past due after 30 days from your statement date. Account balances exceeding 90 days in age from time of service may be forwarded to a collection agency. All costs incurred in collecting unpaid fees will be charged to your account. All customers on the account will be discharged from the practice.
- Checks returned by your bank will be subject to a return check fee.
Out of Network Insurance

(Please skip if you are using in network insurance)
I understand that my insurance company nameinsurance is "out of network" with smiles4children and benefits cannot be specifically determined. The amount due at time of service is an estimate only and I will be responsible for any balance not paid by insurance. Initial
Parent/Guardian Name*
Signature*

Clear
Date*

MonthDayYear

DRS. GINSBERG, SIMON, SHROFF, JAHNIGEN AND ASSOCIATES
NOTICE OF PRIVACY PRACTICES

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 (MM/DD/YR), 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 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 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 authorize 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. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.60 for each page, $18 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

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, but not before April 14, 2003. 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 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 would like 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.

Contact: Dr. Edward Ginsberg, Deven Shroff, & Rachael Simon

1134 North Rolling Road, Catonsville, MD 21228 410-788-4555

10045 Baltimore National Pike, Suite A-1, Ellicott City, MD 21042 410-203-2410

5961 Exchange Drive, Suite 116, Eldersburg, MD 21784 410-549-1212

© 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
Drs. Ginsberg, Simon, Shroff, Jahnigen & Associates
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I have received a copy of this office’s Notice of
Privacy Practices.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Medication	Dose	Frequency	Reason
1
2
3
4

Primary Dental Coverage

Secondary Dental Coverage

Medical Insurance Coverage

Has your child had fluoride in any of the following forms?

Out of Network Insurance