T h e
S m i l e T i m e T e a m
is c o m i n g
t o
s c h o o l !
Louisa County
Jouett Elementary
8/29/14, 11/14, 2/15
Trevilians Elementary
R E G I O N A L D E N T A L CL'fNIC
9/13/14, 12/14, 3/15
Thomas Jefferson Elementary
9/5/14, 12/14, 3/15
Moss Knuckols Elementary
9/10/14, 12/14, 3/15
N o v e m b e r -June dates are tentative based u p o n school schedule,
participation, and weather. C o n f i r m e d dates w i l l be assigned
closer to the time and posted on PRDC's website at www.vaprdc.org
PDRCs S m i l e T i m e T e a m b r i n g s o r a l h e a l t h c a r e t o y o u !
Services provided by the Smile Time Team:
i
-
i
Dental Care Goodie Bag including toothbrush,
•
Comprehensive Dental Exam
•
D i g i t a l x-rays
•
Fluoride Varnish
Report f r o m your child's Smile T i m e visit
•
Prophy (teeth cleaning)
telling
•
Sealants (a t h i n , plastic material painlessly
received and any additional needs
apphed o n the chewing surfaces of the back
Follow up call w i l l be made from a representative
teeth to prevent t o o t h decay)
of our team 72 hours after the Smile T i m e visit
•
toothpaste and flosser
y o u exactly
what care your
child
to help coordinate follow up care i f needed
Return this application w i t h i n 5 days o f receipt w i t h all connpleted
i n f o r m a t i o n t o be seen by t h e Smile Time Team!
•
• •
All children ore eligible for a Snnile Time Visit - See enclosed application for
PRDC is in network with all forms of Virginia Medicaid, Delta Dental,
will also file other dental insurances, and offers discounted
services for those who qualify.
*
P l e a s e
K e e p
T h i s
P a g e
F o r
Y o u r
R e c o r d s
These materials a n d a c t i v i t y described h e r e i n , are n o t sponsored b y the Louisa C o u n t y School B o a r d .
NOTICE OF PRIVACY
PRACTICES
T H I S N O T I C E DESCRIBES H O W H E A L T H I N F O R M A T I O N A B O U T Y O U
M A Y BE U S E D A N D D I S C L O S E D A N D H O W Y O U C A N GET ACCESS T O
T H I S I N F O R M A T I O N . T H E PRIVACY OF YOUR H E A L T H I N F O R M A T I O N
IS I M P O R T A N T T O US.
A b u s e o r N e g l e c t : W e m a y disclose y o u r h e a l t h i n f o r m a t i o n t o a p p r o p r i a t e a u t h o r i t i e s i f w e reasonabl}' b e l i e v e t h a t y o u
are a p o s s i b l e v i c t i m o f abuses n e g l e c t , o r d o m e s t i c v i o l e n c e o r the p o s s i b l e v i c t i m o f o t h e r c r i m e s .
We m a y disclose y o u r
h e a l t h i n f o r m a t i o n t o t h e e x t e n t necessary t o a v e r t a s e r i o u s t h r e a t t o y o u r h e a l t h o r safety o r the h e a l t h o r safoty o f o t h e r s .
N a t i o n a l S e c u r i t y : W e m a y d i s c l o s e t o m i l i t a r y a u t h o r i t i e s the h e a l t h i n f o r m a t i o n o f . ' I r m e d Forces p e r s o n n e l u n d e r c e r t a i n
c i r c u m s t a n c e s . W'e m a y d i s c l o s e t o a u t h o r i z e d f e d e r a l o f f i c i a l s h e a l t h i n f o r m a t i o n r e q u i r e d f o r l a w f u l i n t e l l i g e n c e , c o u n t e r i n t e l l i g e n c e , a n d o t h e r n a t i o n a l securit)- a c t i v i t i e s . W^e m a y disclose t o c o r r e c t i o n a l i n s t i t u t i o n o r la^v e n f o r c e m e n t o f f i c i a l
OUR LEGAL DUTY
l:\aving la-^vful c u s t o d y o f p r o t e c t e d h e a l t h i n f o r m a t i o n o f i n m a t e o r p a t i e n t u n d e r c e r t a i n c i r c u m s t a n c e s .
AVe are r e q u i r e d b y appUcabie federal a n d state lnv t o m a i n t a i n t h e p r i v a c y o f yous' h e a l t h i n l b r m a t i o n . We are also r e q u i r e d
to g i v e )-ou- t h i s M o t l c e a b o u t o u r privac)•-p^aetieesrour^!egai^tiuttes,
and your riglits concerning your health i n f o r m a t i o n .
W e m u s t f o l l o w t h e p r i v a c y p r a c t i c e s t h a t are d e s c r i b e d i n t h i s N o t i c e ^ d i i l e i t is m effect. ' I h i s N o t i c e takes eifect 04/01/0."''
Appointment Reminders:
\Vc m a y use o r discfose y o u r h e a l t h i n f o r m a t i o n to p r o v i d e y o u w i t h a p p o i n t m e n t r e m i n d e r s
( s u c i i as v o i c e m a i i messages, p o s t c a r d s , o r l e t t e r s ) .
, a n d w'Wi r e m a i n h i effect unti,i we r e p l a c e it,
AVe reserve the r i g h t t o change o u r p r i v a c y practices a n d the t e r m s o f t h i s N o t i c e at any t i m e , p r o v i d e d such changes are
p e r m i t t e d b y a p p l i c a b l e law. W e reserve the r i g h t t o m a k e t h e changes i n o u r p r i v a c y p r a c t i c e s a n d t h e new
t e r m s o f ouj"
N o t i c e effective for a!) h e a l t h i n f o r m a t i o n tlsat w e m a i n t a i n , i n c l u d i n g h e a l t h i n f o r m a t i o n we c r e a t e d o r received b e i b r e w e
m a d e t h e changes. B e f o r e w e m a k e a sig.nilicant c h a n g e i n o u r p r i v a c y practices, w e H ' i l l change t h i s N o t i c e a n d m a k e the
n e w N o t i c e available u p o n request.
t,hat w e p r o v i d e copies i n a f o r m a t o t h e r t h a n p h o t o c o p i e s .
You m a y request
W e w i l l use t h e f o r m a t y o u r e q u e s t unless we c a n n o t
practicably
d o so. ( Y o u m u s t m a k e a r e q u e s t i n w r i t i n g t o o b t a i n access t o y o u r h e a l t h i n f o r m a t i o n . Y o u m a y o b t a i n a f o r m t o request
access b y u s i n g t h e c o n t a c t i n f o r m a t i o n l i s t e d at t h e e n d o f t h i s N o t i c e . Y o u m a y also r e q u e s t access b y s e n d i n g us a l e t t e r t o
t h e address at t h e e n d o f t h i s N o t i c e , [ f y o u request copies^ w e w i l l n o t c h a r g e y o u f o r each page, f o r .staff t i m e t o l o c a t e a n d
Yoii-may-request a copy-ol'our-Nolice-a!: an)' l i n i e . - T o r n u j r e
infomiaiioo
o f this N o t i c e , please c o n t a c t us u s i n g t h e i n f o r m a t i o n listed at t!te end
USES A N D D I S C L O S U R E S O F H E A m i
PATIENT RIGHTS
Access: Y o u h a v e t h e r i g h t t o l o o k at o r get c o p i e s o f y o u r h e a l t l i i n f o r m a t i o n , w i t h l i m i t e d e x c e p t i o n s .
a b o u t o u r p i i v a c y p r a c t i c e s , o r for a d d i t i o n a l copies
o f this Notice.
c o p y y o u r h e a l t h i n f o r m a t i o n , a n d postage i f y o u w a n t t h e c o p i e s m a i l e d t o y o u .
Restriction;
Y o u have t h e r i g h t to request t h a t w e place a d d i t i o n a l r e s t r i c t i o n s o n o u r use o r d i s c l o s u r e o f y o u r h e a l t h
information.
W e are n o t r e q u i r e d to agree t o these a d d i t i o n a l i e s t r i c t i o j L s , b u t i f we d o , w e w i l l abide by o u r a g r e e m e n t
(excepH i n a n e m e r g e n c y ) .
INF'ORMATION
A l t e r o a t i v e C o m m u n i c a t i o n : Y o u have the r i g h t t o request t h a t w e c o m m u n i c a t e w i t h y o u a b o u t y o u r h e a l t h i n f o r m a t i o n
W e use a n d disclose h e a l t h i n f o r n i a t i f s n a b o u t y o u hv t r e a t n i e i i t , p a y m e n t , a n d liealtlscare ijperation.s. For e x a o i p j e ;
W e U i a y use o r disclose y o u r h e a l t h i n l o r n s a t i o n t o a p h y s i c i a n o r o t h e r h e a l t h c a r e p r o v i d e r p r o v i d i n g t r e a t -
Treatment:
b y a l t e r n a t i v e m e a n s o r t o a l t e r n a t i v e l o c a t i o n s . (You m u s t m a k e y o u r request i n - w r i t i n g . } " " Y o u r request m.ust s p e c i f y the
a l t e r n a t i v e m e a n s o r l o c a t i o n , a n d pirovide satisfact<.)ry e,!cpianation h o w p a y m e n t s w i l l be h a n d l e d u n d e r t h e a l t e r n a t i v e
m e a n s o r l o c a t i o n y o u request.
m e n t to y o u .
A m e n d r a e n t : Y o n have the r i g h t t o reqitest t h a t w e a m e n d yo'ur h e a l t h i n f o r m a t i o n . ( Y o u r request m u s t be i n - w r i t i n g , a n d
Payment:
We m a y use a n d discJose y o u r h e a l t h i n f o r m a t i o n to o b t a i n paj^inent f o r services w e p r o v i d e t o y o u .
Healthcare Operatiosis:
W e m a y use a n d disck?.se y o m - h e a l t h i n f o r m a t i o n i n c o n n e c t i o n w i t h o u r healthcare o p e r a t i o n s .
H e a l t h c a r e o p e r a t i o n s i n c l u d e q u a l i t y assessment a n d i m p r o v e m e n t act i vi t i es , r e v i e w i n g the c o m p e t e n c e o r q u a h t k a t i o n s
it m u s t e x p l a i n -why the i n f o r m a t i o n s h o u l d be a m e n d e d . )
W e m a y d e n y y o u r request u n d e r c e r t a i n c i r c u m s t a n c e s .
E l e c U - o n k N o t i c e ; If y o u receive t h i s N o t i c e o n o u r w e b site o r b y e l e c t r o n i c m a i l ( e - m a i i ) , y o u are e n t i t l e d t o receive this
Notice i n .written form..
-
o f healthcare pr of e s s i ona l s , e v a l u a t i n g p r a c t i t i o n e r a n d p r o v i d e r p e r f o r m a n c e , e o n d u c l i n g t r a i n i n g p r o g r a m s , a c c r e d i t a t i o n r
certification, licensing or credentialing activities.
Vouv A u t h o r i z a t i o n :
I n a d d i t i o n t o o u r use o f y o u r h e a l t h i n f o r m a t i o n f o r t r e a t m e n t , p a y m e n t o r h e a l t h c a r e o p e r a t i o n s ,
y o u n i a y give us w r i t t e n a u t h o n z a t i o n t o use v o u r h e a l t h i n f o r m a t i o n o r to disclose i t t o a n y o n e for a n y p u r p o s e . I t y o u give
us an a u t h o r i z a t i o n , y o u m a y r e v o k e it i n - w r i t i n g at a n y t i m e . Y o u r r e v o c a t i o n w i l l n o t affect a n y use o r disclosures p e r m i t t e d
b y y o u r a u t h o r i z a t i o n w h i l e i t was i n elfect. Unless y o u give us a w r i t t e n a u t h o r i z a t i o n , w e c a n n o t use o r disclose y o u r h e a l t h
i n f o r m a t i o n fo.r a n y r e a s o n except t h o s e d e s c r i b e d i n t h i s N o t i c e .
c e r n e d t h a t w e ma)'" h a v e v i o l a t e d y o u r p r i v a c y r i g h t s , o r y o u disagree with
T o Y o u r F a m i l y a n d F r i e n d s : W e m u s t disclose y o u r h e a l t h i n f o r m a t i o n t o y o u , as d e s c r i b e d i n t h e Patient R i g h t s .section
o f thj.s N o t i c e . W e ma)- disclose y o u r h e a l t h i n f o r m a t i o n t o a f a m i l y m e m b e r , f r i e n d o r o t h e r p e r s o n t o t h e e x t e n t necessar)'
to iteip w i t h y o u r h e a l t l i c a r e o r w i t h p a y m e n t f o r y o u r healthcare, b n t o n l y ifyo-u agree t h a t w e m a y d o so.
P e r s o n s I n v o l v e d In C a r e :
We m a y u.se or disck)se h e a l t h i n f o r m a t i o n t o n o t i f y , o r assist i n t h e n o t i f i c a t i o n o f ( i n c l u d i n g
i d e n t i f y i n g o r l o c a t i n g ) a f a m i l y m e m b e r , )-our p e r s o n a l representative o r a n o t h e r p e r s o n r e s p o n s i b l e f o r y o u r care, o f y o u r
l o c a t i o n , y o u r g e n e r a l c o n d i t i o n , o r d e a t h . I f y o u a!~e present, t h e n p r i o r t o use o r d i s c l o s u r e o f y o u r h e a l t h i n f o r m a t i o n , w e
w i l l p r o v i d e y o u w i t h a n o p p o r t u n i t y t o o b j e c t t o such uses o r disclosures,
QUESTIONS A N D COiMPLAINTS
i f v o u w a n t m o r e i n f o r m a t i o n a b o u t o u r p r i v a c y practices o r have q u e s t i o n s or c o n c e r n s , please c o n t a c t us. I ! y o u are c o n -
h i t h e event o f y o u r i n c a p a c i t y o r e m e r g e n c y c i r -
a d e c i s i o n we m a d e a b o u t access t o y o u r h e a l t h
i n f o r m a t i o n o r i n response t o a request y o u m a d e t o a m e n d o r r e str i c t t h e use o r d i s c l o s u r e o f y o u r h e a l t h i n f o r m a t i o n o r
to h a v e us c o m m u n i c a t e w i t h y o u b y a l t e r n a t i v e m e a n s o r at a l t e r n a t i v e k>cations, y o u m a y c o m p l a i n t o us u s i n g t h e c o n t a c t
i n f o r m a t i o n h s t e d at t h e e n d o f t h i s N o t i c e .
Y o u also m a y s u b m i t a w r i t t e n c o m p l a i n t t o the U.S. O e p a r t m e . a t o f H e a l t h
a n d H u m a n Services. W e w i l l p r o v i d e y o u w l t l i the address t o (ile y o u r c o m p l a i n t w i t h the U.S. D e p a r t m e n t o f H e a U h a n d
H u m a n Services u p o n r e q u e s t .
W e s u p p o r t y o u r r i g h t t o t h e p r i v a c y o f y o u r h e a l t h i n f u r m a t i o n . W e will
not retaliate i n a n y w a y i f y o u c h o o s e to file a
c o n : ( p b i n t wiih. u.s o r w i t h t h e U.S. D e p a r t m e n t o f Healtbi a n d H u m a n Services.
c u m s t a n c e s , W'e will d i s c l o s e h e a l t h i n f o r m a t i o n based o n a d e t e r m i n a t i o n u s i n g o u r p r o f e s s i o n a l j u d g m e n t d i s c l o s i n g o n l y
h e a l t h i n f o r m a t i o n t h a t is d i r e c t l y r e l e v a n t t o t h e p e r s o n s i n v o l v e m e n t In y o u r h e a l t h c a r e .
W e w i l l also use o u r p r o f e s s i o n a l
j u d g m e n t a n d o u r e x p e r i e n c e w i t h c o m m o n p ract i ce t o m a k e reasonable inferences o f )'our best i n t e r e s t i n a l l o w i n g a p e r s o n
to p i c k u p f i l l e d p r e s c r i p t i o n s , m e d i c a l supplies, x - r a y s , o r o t h e r s i m i l a r f o r m s o f heaUh i n f o r m a t i o n .
M a r k e t i n g H e a l t h - R e l a t e d S e r v i c e s : W e w i l l n o t use y o u i ' h e a l t h i n f o r m a t i o n f o r m a r k e t i n g c o m m u n i c a t i o n s ^S'lthoui y o u r
Contact: Kelli M.itchel!
Telephone: 540-661--OOOS
Fiix: 540-661-1070
Avritten authorization.
E-mail: liifo^^vaprdcorg
R e q u i r e d b y L a w : W e m a y use o r d i s c l o s e y o u r h e a l t h i n f o r m a t i o n ^vhen we are r e q u i r e d to d o so by law.
Address: 13296 James Madison Highway * Orange. YirgiBia 22960
PLEASE RETURN WITHIN 5 DAYS.
H
REGIONAL DENTAL CLINIC
P r i n t clearly i n i n k and c o m p l e t l y f i l l out the f o r m . Signature is required for y o u r c h i l d to be treated.
Patient Demographics
School or O r g a n i z a t i o n ,
_County_
Teacher/Care Manager_
Room #
Child's Legal Name
Date of B i r t h
Male
Female
Race: W h i t e
Black/African
American
Grade
Asian
Other
Parent/ Gaurdian / Responsible Party I n f o :
Na m e;
.Contact Number (
_City^
Address:
Relationship to C h i l d _
State
_County
_Zip_
Email
Is this your very first visit to a dentist? Y or N
When was your child's last dental checkup?
I f no please provide the name of the dentist visited;_
Health & Medical Information
Please list any medications your child is currently taking:_
Please
check
the
box
that
apphes
to
the
patient
Has the child had any history o f or conditions related to, any of the following:
None
_,Asthma
_Seizures
_Blood Disorders
_Shunts or Artificial Joints
Diabetes
Latex Allergy
Heart M u r m u r (requiring pre-medication)
Heart M u r m u r (not requiring pre-medication)
Allereies:
Hemophilia
_ADHD
_Hepatitus
_Kidney Problem
_HIV/AIDS
.Tuberculosis
_Heart Valve Replacement
Other:
Medicaid
M y c h i l d is c o v e r e d b y V i r g i n i a
Medicaid/FAMIS.
12 digit Medicaid I D number:
Dental Insurance
My child is covered by a commercial dental insurance and I would like to have their Smile Time" visit submitted to their insurance.
Insurance Company Phone:.
Insurance Carrier:
Relationship to patient:
Subscriber:
Birth date of subscriber:.
Phone number of subscriber:
Employer Name:
Insurance I D #
Insurance Group #:_
Uninsured L o w Income Families
M y child does not have Medicaid or dental insurance; however does receive free or reduced lunch or our family income is at 200% or below federal poverty
guidelines. I understand there is a $50 discounted rate for financially qualifying, (please circle w h i c h category applies to your annual household income)
Family Size
2
3
A n n u a l Household Income
Family Size
A n n u a l Household Income
$31,460
5
$55,820
6
$63,940
S39,580
4
$47,700
] have attached a $50 money order for the Smile T i m e " visit.
I w o u l d like to pay by Visa/Mastercard ~ Please call me a t .
No Medicaid, No Dental Insurance, or Financially Overqualified for discounted visit
M y child does not have Medicaid, Dental Insurance, and our family's household is 200% or above Federal Poverty Guidelines.
t have attached a $125 money order for the Smile T i m e " visit.
t w o u l d like to pay by Visa/Masterard - Please call me at
IMPORTANT: Parent/Guardian Sianature Reauired
Consent for Services and Care: As a custodial parent or legal guardian of the child listed above, I authorize PRDC to treat the above named patient and disclose, w h e n requested, any and all i n f o r m a t i o n for any illness or Injury, medical history consultation, prescriptions or treatment and
copies of all medical records, 1 assign or authorize direct payment t o the designated practiced t o w a r d any medical procedures p e r f o r m e d and authorize PRDC to file claims o n my behalf. I agree that this authorisation shall be valid until rescinded in w r i t i n g or replaced by one of 3 later
date. A p h o t o c o p y of this authorization shall be considered effective and valid as the original. I understand that I am responsible for services n o t covered by my Insurance plan, as well as for services rendered if i d i d not choose PRDC as my Primary Care Provider or If my Insurance Is not in
effect at the time o f service. I understand that PRDC renders services w i t h o u t regard t o race, creed, color or national origin. By my signature 1 acknowledge that 1 have been i n f o r m e d of Virginia state law regarding b l o o d testing: In event that a health care provider or employee is exposed
to the patient's b o d i l y fluids In a manner w h i c h may transmit disease, the patient will be d e e m e d to have consented to testing for HIV and hepatitis and to release or disclosure of the test results to that health care provider or employee. I allow for school nurse/school representatives,
and/or the dentist of my choice to o b t a i n dental records and radiographs. I acknowledge receiving a notice of privacy practices before signing. I understand my child will receive a dental treatment plan and a contact f o l l o w up call will be made w i t h i n 72 hours o f the dental visit.
I understand by signing this consent is valid for the entire school year. If I decide to o p t o u t I must provide a o p t o u t letter to PRDC, PC Box 151, Orange, VA 22950.
X S I G N
Date
HERE
(Parent/Guardian)
P i e d m o n t Regional Dental Clinic - 13296 James Madison H w y • PO Box 151 • Orange, Virginia 22960
Office: 540.661.0008 • Fax: 540.661.1070 • w w w . v a p r d c . o r g
Who is eligible for FAMIS?
Virginia offers several l o w a n d n o cost health insurance p r o g r a m s f o r
eligible children, p r e g n a n t w o m e n a n d adults. To f i n d o u t m o r e a b o u t
each p r o g r a m visit w w w . f a m i s . o r g
Famis Plus (Children's Medicaid) & M e d i c a i d f o r Pregnant W o m e n u p t o
143%FPL
Family Size
Yearly
Monthly
1
2
3
4
$16,688
$22,494
$28,300
$34,106
$39,911
$45,717
$1,391
$1,874
5
6
7
8
Additional person add
$51,523
$57,329
$5,806
$2,358
$2,842
$3,326
$3,810
$4,294
$4,777
$484
F A M I S (for children) - up to 200% FPL
Family Size
Yearly
Monthly
1
2
$23,340
$31,460
$39,580
$1,945
$2,622
$3,298
$47,700
$55,820
$63,940
$72,060
$80,180
$3,975
$4,652
3
4
5
6
7
8
$5,328
$6,005
$6,682
A n additional 5% FPL "Standard Disregard" may be applied i f a family is over the upper boundary o f the income shown above for all
programs; for 1 person subtract $49 from the family's gross income; for 2 $66; for 3 $82; for 4 $99; for 5 $116; for 6 $133; for 7 $150;
for 8 $167; for any more subtract an additional $17 each.
I f you require assistance or more information on how you can apply, please contact Kelli Mitchell, Executive Director at 540-661-0008.
We are here to help!