Welcome!
My staff and I are delighted that you have chosen our office to care for your child’s dental
needs.
Our mission is to care for your child with compassion and respect, promote sound teeth and a
healthy lifestyle. We are proud to provide a relaxing, child friendly environment, specifically
designed to engage your child. Our open door policy invites parents to accompany their
children into the treatment areas. Our goal is for your child to have a positive dental experience.
We offer a variety of treatment options to help alleviate an anxious child. These include: Nitrous
oxide (or laughing gas), in office conscious sedation, as well as general anesthesia in a
comfortable, hospital type setting. Our friendly and expert staff is great with children, adding to
the caring and nurturing atmosphere of our office.
We accept and file most insurance as a courtesy and convenience to you. Financing is also
available with approved credit.
We are happy to welcome your child as a new patient and hope to help him or her to maintain a
beautiful, healthy smile for a lifetime.
Sincerely,
Karen M. Sept, DMD
And Staff
Patient’s Name: _______________________
Date of Birth:____/____/________
Page 1
Patient’s Name: _______________________
Date of Birth:____/____/________
Page 2
New Patient Information
Child’s Name __________________________________________ Nickname ________________________
DOB: ___/___/______
Male____ Female____
Responsible Party Information
MOTHER/GUARDIAN
Name__________________________________ Home Phone______________Cell Phone______________
Spouse Name_________________________________Cell Phone_______________
Address___________________________________City_________________State____Zip_______________
Email Address__________________________________________________
Mother’s Employer______________________________ Address____________________________________
Mother’s Social Security Number________-_____-__________ Mother’s DOB_____/_____/__________
FATHER/GUARDIAN
Name__________________________________ Home Phone______________Cell Phone______________
Spouse Name_________________________________Cell Phone_______________
Address___________________________________City_________________State____Zip_______________
Email Address__________________________________________________
Father’s Employer______________________________ Address____________________________________
Father’s Social Security Number________-_____-__________ Father’s DOB_____/_____/__________
EMERGENCY CONTACT
Name______________________________________ Phone Number(s)______________________________
CHILD’S INSURANCE (Please document insurance coverage in addition to the following on the reverse of this form)
Dental Insurance Company that Covers the Child ________________________________________________
Subscriber’s Name ______________________________ Date of Birth _____/_____/__________
Group Number _______________________ ID Number _______________________
Has any other immediate family member been treated in this office? _________________________________
How did you hear about our practice? _________________________________________________________
I authorize my insurance benefits to be paid to Dr. Karen Sept. I also authorize Dr. Karen Sept to release any information required for all
insurance claims.
I acknowledge that I am financially responsible for all charges whether or not they are paid by insurance. If I desire credit to be extended to
me and/or my family for services rendered, I am aware that a credit report may be obtained before credit is extended
Signed________________________________________________ Date_____/_____/__________
Additional Insurance Coverage
SECONDARY INSURANCE
Dental Insurance Company that Covers the Child ________________________________________________
Subscriber’s Name ______________________________ Date of Birth _____/_____/__________
Group Number _______________________ ID Number _______________________
TERTIARY INSURANCE
Dental Insurance Company that Covers the Child ________________________________________________
Subscriber’s Name ______________________________ Date of Birth _____/_____/__________
Group Number _______________________ ID Number _______________________
Notice of Privacy Practices
This notice describes how medical information about your child may be used and disclosed, and how you can get access to this
information. We are required by law to provide you with this notice of our privacy practices. PLEASE REVIEW IT
CAREFULLY.
Palouse Pediatric Dentistry (PPD) maintains a record of the dental services we provide to your child. This includes
symptoms, our findings, test results, diagnoses, and treatment provided, as well as health information from other providers and
billing and payment information related to these services. Federal and state laws allow us to use this information to provide care
for your child while also requiring us to protect the privacy of their information.
We respect you and your child's privacy. We understand that your child's personal health information is very sensitive.
We will never disclose you or your child’s health information to others unless you tell us to do so, or the law authorizes or
requires us to do so.
How Your Child's Health Information is Used
I. For Treatment:
- Information will be used to help decide what care may be right for your child.
- This information may be shared with other health care providers who are caring for your child.
II. For Payment:
- Diagnoses, procedures performed, or recommended care may be provided to your dental insurance plan so that we
may receive payment from them.
- You may opt to restrict the disclosure of your child's personal health information to your dental insurance
company/companies. We will gladly respect your wishes in this regard:
However, this will require that you pay entirely out-of-pocket at the time of service.
III. For Health-Care Operations:
- Information may be used to assess and improve the quality of care we provide
- We may contact you to remind you about upcoming appointments.
- Information may be used to conduct or arrange for services, including:
- Quality review by your health plan
- Accounting, legal, risk management, and insurance services
- Audit functions, including fraud and abuse detection and compliance programs
Your Health Information Rights
The health and billing records we create and store are the property of PPD. The protected health information in it, however,
generally belongs to you.
You have a right to:
- Receive, read, and ask questions about this Notice, as well as obtain a copy of this notice for your records
- See and obtain a copy of your child’s protected health information. You may request that this information; be
provided to you in written or electronic format. Please make this request in writing.
- Ask us to change your child’s health information. Please make this request in writing.
- Receive a list of disclosures of your child’s health information (excluding disclosures to third-party payers)
- Cancel prior authorizations to use or disclose health information. Again, please provide this request in writing
- Ask us to restrict certain uses and disclosures of your child's health information. You must deliver such a request in
writing to us. Though we are not required to grant your request, if we are able and do grant it, we will comply with
your wishes.
Our Responsibilities
We are required to:
- Keep your child’s protected health information private
- Give you this notice
- Follow the terms laid out in this notice
We may change our practices regarding the protected health information we maintain. If we make changes, we will update this
notice. You may receive the most recent copy of this notice by calling and asking for it or by visiting our office to pick one up.
To Ask for Help or Make a Complaint
If you have questions, want more information, or want to report a problem about the handling of your child’s protected health
information, you may contact the Practice Administrator during regular business hours. You may also deliver a written
complaint to the Practice Administrator. You may also file a complaint with the U.S. Secretary of Health and Human
Services. If you file a complaint, we will not retaliate against you in any way.
Other Disclosures and Uses of Protected Health Information
I. Notification to Family and Others
- We will only release your child's health information directly to a legal guardian.
- We may also give information to someone who helps pay for your child's care.
- We may release health information about your child to a friend or family member, but only at your request or with
your approval.
- In the unlikely event of an emergency where it is necessary for us to inform your family of your child's location and
general well being. The person contacted will be, if at all possible, the individual you designate to contact in case of
emergency.
If you are not comfortable with and do not agree with any of these policies and practices regarding your child's health
information privacy, please inform us and we will do our best to follow your wishes.
II. Other situations where your child's health information may be used without your authorization:
-To an Outpatient Facility: Relating to provision of anesthesia services for surgical procedures
-To the Food and Drug Administration: Relating to problems with regulated products
-To Comply with Workers' Compensation Laws
-For Public Health and Safety Purposes as Allowed or Required by Law, to prevent or reduce a serious threat to
the health or safety of a person or the general public.
-To Report Suspected Abuse or Neglect to public authorities
-For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you or
your child are victims of a crime.
-For Health and Safety Oversight Activities: For example, we may share health information with the Department of
Health.
-For Work-Related Conditions that Could Affect Employee Health: For example, an employer may ask us to
assess health risks on a job site.
-To the Military Authorities of U.S. and Foreign Military Personnel if you or another parent/guardian are enlisted.
-In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
-For Specialized Government Functions. For example, we may share information for national security purposes.
-In the event of the patient's death we may disclose relevant protected healthcare information of the deceased patient
to a family member, friend, or representative, if that family member, friend, or person had been involved in the patient's
care or payment before death, unless disclosure would be inconsistent with the patient's express wishes to the practice.
III. Other Uses and Disclosures of Protected Health Information will be made only as allowed or required by law or with
your written authorization. This includes, but is not limited to:
- The transfer of your child’s records to a doctor who did not refer you to PPD, or you were not referred to by
PPD. For example, if you move from the area, and see a new doctor, a signed release is required in order for PPD to
release your records to that doctor.
-The transfer of your child’s records in the course of judicial/administrative proceedings at your request or as
directed by a subpoena or court order.
Should there be a security breach that potentially affects patient privacy and protected health information, we are required to:
-Notify patients
-Take steps to mitigate the damage
-Notify the Department of Health and Human Services (HHS)
We have a web site that provides information about us. For your benefit, this notice is on the website at this
address: http://www.palousepediatricdentistry.com/office.htm
This Notice Effective 13 March 2014