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 i i o o l !
Culpeper County
R E G I O X A I .
D E N T A L
Farmington Elementary
09/19/20114,01/2015, 03/2015
A G Richardson Elementary
09/22/2014,01/2015, 03/2015
Emerald Hill Elementary
09/24/2014,01/2015,03/2015
C L I X I C
Yowell Elementary
10/07/2014,01/2015,04/2015
Sycamore Park Elementary
10/02/2014,01/2015, 04/2015
Pearl Sample Elementary
10/06/2015,01/2015,04/2015
F T Binns Middle and Culpeper Middle School
"o be determined based upon participation return forms to school by 09/30/2014
November -June dates are tentative based upon school schedule,
participation, and weather. Confirmed dates will be assigned
closer to the time and posted on PRDC's website at mw.vaprdc.org
PRDCs Smile Time Team brings oral health care to you!
Services provided by the Smiie Time Team:
•
•
•
•
•
Comprehensive Dental Exam
Digital x-rays
Fluoride Varnish
Prophy (teeth cleaning)
Sealants (a thin, plastic material painlessly
applied on the chewing surfaces of the back
teeth to prevent tooth decay)
Dental Care Goodie Bag including toothbrush,
toothpaste and flosser
Report from your child's Smile Time visit
telling you exactly what care your child
received and any additional needs
Follow up call will be made from a representative
of oiir team 72 hours after the Smile Time visit
to help coordinate follow up care if needed
Return this application within 5 days of receipt with all connpleted
information to be seen by the Smile Time Team!
• • •
All children are eligible for a Smile Time Visit - See enclosed application for specifics.
PRDC is in networi( with ali forms of Virginia Medicaid, Delta Dental,
will also file other dental insurances, and offers discounted
services for those who qualify.
* Please Keep This Page For Your Records
These materials and activity described herein, are not sponsored by the Culpeper County School Board.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
MAY BE USED A N D DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. THE PRIVACY OF YOUR HEALTH INFORMATION
IS IMPORTANT TO US.
A b u s e o r N e g k c l t \Ve may
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 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 \vt: reasonabl}'' b e l i e v e t h a t y o n
are a p o s s i b l e v i c t i m o f abuse, n e g l e c t , o r d o m e s t i c v i o l e r i 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 .
W e m a y disclose y o u r
j i e a l t h i n f o r j n a t i o n t o t h e e x t e n t n e c e s s a r i ' t o a v e r t a serious t h r e a t t o y o u r h e a l t h o r safety o r t h e h e a l t h o r s a f e t y 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 . \ r m e d F o r c e s 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 ofHclals 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 s e c u r i t y activitievS. 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
OURLEGALDUTY
h a v i n g l a w f u l custody o f protected health i n f o r m a t i o n o f inmate or p a t i e n t under certain
official
circtmistances.
W e are r e q u i r e d b y a p p i i c a b i e federal a n d stale l a w U> m a i n t a i a fhe p r i v a c y *-sf ) ' o u f i^eaUh i n i b n n a i - i o i s . W e are -dho r e q u i r e d
So give y o u t h i s N o t i c e a b o u t o u r p r i v a c y p r a c t i c e s , o u r legal d u t i e s , a n d y o u r r i g h t s c o n c e r n i n g y o u r h e a l t h i n i o n r i a t i o n .
W e must
f o l l o w the 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 w'hile it K i n eifect. l l i i s N o t i c e takes effect 04/01/03
A p p o i n t m e n t ReiniiKlers:
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 t o 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
reminders
( s u c h as v o i c e r n a i l messages, p o s t c a r d s , o r l e t t e r s } .
, a n d w i l l r e m a i n i n eifect u n t i l w e r e p l a c e i t .
We
reserve t h e r i g h t t o c h a n g e o u r p r i v a c y practices a n d t h e t e r m s o f t h i s N o t i c e at a n y time,
p r o v i d e d s u c h c h a n g e s are
p e r m i t t e d b y a p p l i c a b l e l a w . W e reserve the r i g h t t o m a k e t h e cisanges 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
terms o f our
N o t i c e e f f e c t i v e f o r a l l l i e a i t h i n f o r m a t i o n t h a t 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 t b r m a l i o . t t wc c r e a t e d o r r e c e i v e d b e f o 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 s i g n i f i c a n t c h a n g e i n o u r p r i v a c y p r a c t i c e s , w e w i l l change t h i s N o t i c e a n d m a k e
the
PATIENT RIGHTS
.Access: Y o u h a v e the r i g h t t o l o o k a l o r get c o p i e s o f y o u r h e a h h 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 .
tiuil we p r o v i d e copies i n a f o r m a t other t h a n photocopies.
d o so.
You m a y reqiiesl
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 w e c a n n o t
practicably
( Y o u m u s t m a k e a rec|uest 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 request access b y s e n d i n g u.s a letter to
n e w N o t i c e available u p o n r e q u e s t .
t h e a d d r e s s at t h e e n d o f t h i s N o t i c e , i f y o n i - e q u e s t 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 s t a f f t i m e t o locate a n d
Y o u m a y request a c o p y o f o u r N o t i c e at a o j a i m e . f o r m o r e i n f o r m a t i o n a b o u l o u r p r i v a c y p r a c t i c e s , o r f o r a d d i t i o s i a l copies
o f t h i s 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 l i s t e d at the e n d o f t h i s N o t i c e .
USES A N D DISCLOSURES OP HEALTH INFORMATION
c o p y y o u r h e a l t h j n f t j r m a t i o n , a n d postage i f y o u w a n t t h e copies m a i l e d t o y o u .
Re.siriclio.n;
Y o u have t h e r i g j i t t o request t h a t w e p l a c e 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 u s e o r d i s c l o s u r e o.t y o u r h e a l t h
intbrmatlon.
W e are n o t r e q u i r e d t o agree t o ihese a d d i t i o n a l r e s t r i c t i o n s , b i U i f w e d o , w e w i l l a b i d e b y o u r a g r e e m e n t
(except i n a n
emergency).
A l t e n i a t i y e C o m m i n i I c a t i o n : Y o u h a v e the r i g h t t o request t h a t SVQ 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 n s a t i o n
We use arid disclose health, i a f o m i a t i o n a b o u t y o u f o r treatinerd-, pavivient, a a d h e a l t h c a r e o p e r a t i o n s .
For example:
b y a l t e r a a i i v e m e a n s o r t o a l t e r n a t i v e iocations^ { Y o u m u s t m a k e y o u r r e q u e s t i n \ S T i t i n g . }
Y o u r request m u s t specif}' 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 p r o v i d e s a t i s f a c t o r y e x p l a n a t i o n 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
Treafment:
We m a y use o r disclose y o u r h e a l t h i n f o n r i a i i o n lo a p l r y s i c i a n o r oSber iseaithcare j > r o v i d e r p r o v i d i n g (.real''
m e n t to y o u .
r n e a n . s o r l o c a t i o n you. r e q u e s t .
A . n ! e i K i m e i i t ; Y o u h a v e t h e r i g h t t o request t h a t ^ve a m e n d y o u r h e a l t l i i n f o r m a t i o n . ( Y o u r r e q u e s t inisst be i n - w r i t i n g ,
Payment:
W e .may use a n d disclose y o u r h e a l t h i r d b r m a t i o n to o h t a i o p a / i u e a t f o r services w e p r o v i d e t o y o u .
Healthcare Operations:
\Vc m a y use a n d disclose y o L t r 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 i i e a h h c a r e o p e r a t i o n s .
-+ie;il^he.H'e-ejpenttions-ttieitttie-tp:t;tfily assesstnettHttid lnlp^m'emet\Htcti^'^ti^?s^reviCT^4ng th.e C j ' ? m p d c n c c or qiiaiificatK.tns
o f healthcare profcssionais, evaluating p r a c t i t i o n e r a n d p r o v i d e r performance, couducEing t r a i n i n g programs, accreditation,
und
It m u s t e x p l a i n why
t h e i n . f o r i n 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 .
.Electronic N o t i c e ;
Ef yciu receive t h i s N o t i c e o n o u r w e b s i t e o r b y e l e c t r o n i c m a i l ( e - m a i l ) , y o u a r e e n t i t l e d t o receive t h i s
.Notice i n w r i f t c n f o r m .
certification, licensing or credentialing activities.
Y o u r A i i t h o r l s a l 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 i i e a l t b i n l o r m a t i o n t o r t r e a t m e n t , p a y m e n t o r beaU'hcare o p e r a t i o n s ,
you m a y g i v e us \vritten a u t h o r i z a t i o n t o E\se y o u r h e a l t h i r s t o r m a t i o n o r t o disclose i t t o a n y o n e f o r a n y p u r p o s e . I f 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 m ' i v r i t i n g at a n y t i m e . Your r e v o c a t i o n w i l l n o t affect a n y use o r d i s c l o s u r e s 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 w a s i n effect. Unless y o u g i v e us a w r i t t e n a u l h o r i z a t J o a , w e c a n n o t use o r disclose y o u r bealtl.;
i n f o r m a t i o n f o r any r e a s o n e x c e p t 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 .
T o Yom
Family and Friends;
c e r n e d Xhixt w e m a ) ' have v i o i a l e d y o u r p r i v a c y r i g h t s , o r y o u d i s a g r e e w i t h a d e c i s i o n w e m a d e a b o u t access t o y o u r h e a l t h
W e m u s t dlsck)se y o u t heaitis 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 P a t i e n t .Rights s e c t i o n
o f t h i s N o t i c e . W e m a y d i s c l o s e y o u r h e a k h i n f o r m a t i o n t o a .family 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 exre.nt necessary
t o h e l p w i t i i y o u r h e a l t h c a r e o r w i t h p a y m e n t f o r y o u r h e a l t i i c a r e , b u t o n ! ) ' i f y o u agree t h a t we m a y d o so.
Persois.s I n v o l v e d In C a r e :
We m a y use o r disclose 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 , ) ' o u r 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 ) ' o u r care, o f y o i i ) '
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 are p r e s e n t , t i t 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 i i a n o p p o r t u n i t y to o b j e c t t o s u c h uses o r disck)sures.
QUESTIONS A N D COMPLAINTS
I f y 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 p r a c t i c e s o r h a v e cjuestions o r c o n c e r n s , please c o n t a c t us. I f y o u are c o n -
I n 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 cir-
i n f o r m a t i o n o r i n r e s p o n s e t o a request y o u m a d e t o a m e n d o r r e s t r 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
t o h a v e us c o m m u n i c a t e •^vith y o u by a l t e r n a t i v e m e a n s o r at a l t e i T i a t i v e l o c a t i o n s , 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 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 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 t h e U.-S. D e p a r t m e n t o f H e a l t h
a n d H u m a n Services. W e ^vill p r o v i d e y o u w i t h t h e address t o h i e y o u r c o m p l a i n t w i t h t h e U S . D e p a r t m e n t o f H e a l t 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 ) ' 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 o r m a t i o n . W e w i i j n o t r e l a i i a l e i n a i i y way
i f )'ou c h o o s e l o iWe a
c o m p l a i n t ^vitb us o r w i t h t h e 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,
c u m s t a n c e s , w e 'ivifl d i s c l o s e h e a l t h i n f o r m a t i o . a based o n a delern-sination 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 ! s c k ) 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 person's i n v o l v e m e n t h i 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 r a c t i c e t o m a k e reasonable i n f e r e n c e s o f y o u r best interest i n a l l o w i n g a pcr.son
to p i c k u p filled prescriptions, medical supplies, x-rays, or other similar f o r m s o f healih i n f o r m a t i o n .
Mephone: 540-661-0008
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 : \Ve w i l l n o t use y o u r heaUh 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 r a n - i i i n i c a l i o n s ^ v i i h o u t y o u r
w r i i t e n aut]5ori?_ation.
R e q u i r e d b y l o w ; \Ve m a y use o r d i s c l o s e y o u r h e a i t h i i i l b r m a i i o n 'ivhen wo arc recii.uFc;.i. to d o
bv
Contact: Kelli Mitchell
hv/.
Fax: 540-^661-1070
E-mail: [email protected]
Address: 13296 fames Madison Highway • Orange, Virginia 22960
PLEASE RETURN WITHIN 5 DAYS.
Ri-X.IOXAL DENTAL CLINIC
Print clearly in ink and completly fill out the form. Signature is required for your child to be treated.
Patient D e m o g r a p h i c s
School o r O r g a n i z a t i o n ,
_County_
Teacher/Care M a n a g e r _
R o o m #_
Child's Legal N a m e
Date o f B i r t h
Male
Female
Asian
Black/African A m e r i c a n
Race: W h i t e
Grade
Other
Parent/ G a u r d i a n / Responsible Party I n f o :
.Contact Number (
Name:
_City„
Address:
Relationship to C h i l d _
StJte
_County.
_Zip_
Email
Is this your very first visit to a dentist?
Y or N
I f no please provide the name of the dentist visited:_
W h e n was your child's last dental checkup?
Please check the box that applies to the patient
Health & Medical Information
Please list a n y m e d i c a t i o n s y o u r c h i l d is c u r r e n t l y t a k i n g : _
Has the child had any history of, or conditions related to, any o f the following:
Diabetes
_Hemophilia
.Tuberculosis
_Asthma
Latex Allergy
_ADHD
_ H e a r t Valve R e p l a c e m e n t
.Seizures
Heart M u r m u r (requiring pre-medication)
_Hepatitus
_Other:
_Blood Disorders
Heart M u r m u r (not requiring pre-medication)
_Kidney Problem
_ S h u n t s o r A r t i f i c i a l Joints
Allergies:
None
HIV/AIDS
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 M e d i c a i d / F A M I S .
12 digit Medicaid I D number:
Dental Insurance
M y c h i l d is c o v e r e d b y a c o m m e r c i a l d e n t a l i n s u r a n c e a n d I w o u l d l i k e to h a v e t h e i r S m i l e Time™ v i s i t s u b m i t t e d to t h e i r i n s u r a n c e .
Insurance Carrier:
Insurance Company Phone:
Subscriber:
llelationship to patient:.
Phone n u m b e r o f subscriber:
B i r t h date o f subscriber:.
Employer Name:
Insurance Group #
Insurance I D #
Uninsured L o w Income Families
M y child does not have Medicaid or dental insurance; however does receive free or reduced lunch or o u r family income is at 200% o r below federal poverty
guidelines. I understand there is a $50 discounted rate for financially qualifying, (please t i r c l e w h i c h category applies to your annual household income)
Family Size
A n n u a l Household Income
Family Size
A n n u a l Household Income
2
$31,460
5
$55,820
3
$39,580
6
$63,940
4
$47,700
_ I have attached a $50 m o n e y order for the Smile T i m e " visit.
1 would 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 o u r family's household is 200% or above Federal Poverty Guidelines,
I have attached a $125 money order for the Smile T i m e " visit.
I w o u l d like to pay by Visa/Masterard - Please call me at
IMPORTANT: Parent/Guardian S i g n a t u r e Required
Consent for Services and Care: As a custodial parent or legal guardian of the child listed above, I authorize PRDC t o treat the above named patient and disclose, when requested, any and all infofmation for any illness or injury, medical history consultation, prescriptions or treatment and
copies of all medical records. I assign or authorize direct p a y m e n t 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 on my behalf. 1 agree that this authorization shall be valid until rescinded in w r i t i n g or replaced by one of a later
date. A p h o t o c o p y o f this authorization shall be considered effective and valid as the originaL I understand that I am responsible for services n o t covered by m y insurance plan, as well as for services rendered if I d i d not choose PRDC as m y Primary Care Provider or if my insurance is n o t in
effect at the time of service. I understand t h a i PRDC renders services w i t h o u t regard l o race, creed, color or national origin. By m y signature I a c k n o w l e d g e that I have been i n f o r m e d of Virginia state law regarding b l o o d testing: In event tliat a health care provider or employee is exposed
to the patient's bodily fluids in a manner w h i c h may transmit disease, the patient will bo d e e m e d t o have consented t o testing for HIV and hepatitis and t o release or disclosure of the test results to that health care provider or employee. 1 allow for school nurse/school representatives,
and/or the dentist o f my choice to obtain dental records a n d radiographs, I acknowledge receiving a notice of privacy practices before signing. I understand m^ child will receive a dental treatment plan and a contact follow u p call will be made w i t h i n 72 hours of 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 out letter t o PRDC, PO Box 151, Orange, VA 22960.
XSIGN
HERE
Date
(Parent/Guaidian)
P i e d m o n t Regional Dental Clinic - 1 3 2 9 6 J a m e s M a d i s o n H w y PO Box 151 • O r a n g e , 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 low and no cost health insurance progranns for
eligible children, pregnant women and adults. To find out nnore about
each program visit www.famis.org
Famis Plus (Children's Medicaid) & Medicaid for Pregnant Women up to
143% FPL
Family Size
Yearly
Monthly
1
2
$16,688
$22,494
$1,391
$1,874
3
4
$28,300
$34,106
$2,358
$2,842
5
$39,911
$3,326
$45,717
$51,523
$57,329
$5,806
$3,810
$4,294
$4,777
$484
6
7
8
Additional person add
i
FAMIS (for children) - up to 200% FPL
Family Size
Yearly
Monthly
1
$23,340
$1,945
2
3
$31,460
$39,580
$2,622
4
$47,700
5
6
7
$55,820
$63,940
$72,060
8
$80,180
$3,298
$3,975
$4,652
$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 f r o m 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!