We would like to get to know you better!

Please note that all the items below have an impact on dental treatment and we must be aware of your history. To the best of your knowledge, are you currently- or - have you ever been afflicted with:

Authorization

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine needed dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on the form to pay to the dentist all insurance benefits otherwise payable to me for the services rendered. I authorize the use of this signature on all insurance submissions

I authorize the dentist to release all information to secure the payment of benefits. I understand that I am financially responsible for ALL charges whether or not paid by insurance, and that my ESTIMATED patient portion is due at time of service. If you do need to make changes to your appointment please give 2 business days notice. We reserve the right to charge a minimum fee of $75/hr for missed appointments.

1. Insurance: KNOWING AND UNDERSTANDING YOUR INSURANCE BENEFITS IS YOUR RESPONSIBILITY. Payment is due at each appointment regardless of having a contracted billable insurance. Any fees for treatment presented in our office is an ESTIMATE only, fees are provided by YOUR carrier. Anything not covered by your insurance is your responsibility. If you fail to provide us with the correct insurance information in a timely manner, you will be responsible for the full balance of the treatment. I understand It is my responsibility to inform Shumway Dental if I have been to any other dental offices such as specialty offices (root canals, oral surgery, orthodontics.) I understand that any visits to other dental offices may take away from my current dental insurance benefits.

2. Co-payments & Deductibles: All co-payment & deductibles must be paid at the time of service. A $25.00 fee will be charged in the event of a returned check. Non-covered services: Please be aware that any services considered to be a non-covered benefit by your insurance will be your financial responsibility. You are responsible for any non-payment by your insurance company. You should direct any questions &/or complaints regarding your coverage to your insurance carrier.

3. Claim Submission: We will submit claims & assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. As a courtesy, we will submit insurance claims for our patients; however, the agreement of the insurance carrier to pay is a contract between you & the carrier. Federal laws addressing all insurance companies require that we submit claims accurately, we are not allowed to change this information just so an insurance company will pay the claim.

4. Non-payment: If your insurance fails to pay after 90 days, you will be responsible for the balance. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency.

5. Missed & Late Appointment Policy: We understand there may be times when you miss an appointment due to emergencies &/or obligations to work or family. Our office has a 48-business hour cancellation policy. By giving us less than a 48-hour notice or cancelling on a Saturday or Sunday, there will be a $75/hour fee billed directly to you. Please DO NOT leave a message to cancel your appointment. Please help us to serve you better by keeping your regularly scheduled appointment. Please initial the following:

I have read and understand that payment policy and agree to abide by its guidelines.

Shumway dental Care is committed to protecting your privacy, and we have adopted privacy practices to protect the information we gather from you. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. The Notice of Privacy Practices ("Notice") describes the privacy practices of Shumway Dental Care and will tell you about the ways in which we may use and disclose medical information about you and how you can get access to thisinformation. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information with respect to your "Protected Health Information" (as defined by the Health Insurance Portability and Accountability Act of 1996 and its regulations. as amended from time to time).

We typically use or share your health information in the following ways:

•Treat you. We can use your health information and share it with other professionals who are treating you. An example of this would be a doctor treating you for an injury asks another doctor about your overall health condition.
•Bill for your services, We can use and share your health information to bill and get payment from health plans or other entities. An example of this would be sending a bill for your visit to your insurance company for payment.
•Run our office We can use and share your health information to run our practice. Improve your care, and contact you when necessary. An example would be an internal quality assessment review.
How else can we use or share your health information. We are allowed or required to share your information in other ways - usually to contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
•Help with public health and safety issues. We can share health information for certain situations, such as: preventing disease, reporting suspected abuse, neglect, or domestic violence, preventing/reducing a serious threat to anyone's health or safety.
•Comply with law. We can share information about you if state or federal law requires is. including the Department of Health and Human Services.
•Do Research. We can use and share information for health research.
•Family and Friends: We may disclose your health information to a family member or friend who is involved in your medical care or to someone who helps pay for your care. We may also use or disclose your health information to notify (or assist in notifying) a family member, legally authorized representative or other person responsible for your care of your location, general condition or death. If you are a minor. We may release your health information to your parents or legal guardians when we are permitted or required to do so under federal and applicable state law.
•Organ and tissue donation requests. We can share information about you to organ procurement organizations
•Medical examiner or funeral director. We can share information with a coroner, medical examiner, or funeral director when an individual dies.
•Worker compensation law enforcement reauests and other governmental reauests. we can share health information for worker compensation claims. law enforcement purposes. with health oversight agencies for activities allowed by law, and other specialized government functions (e.g., military and national security)
•Lawsuits and legal actions. We can share health information in response to court or administrative order, or in response to a subpoena.

When it comes to your health information, You have certain rights, we typically use or share your health information in the following ways:
•Get an electronic or paper copy of your medical information. You have the right to inspect and/or obtain a copy of your medical information maintained in a designated record set. If we maintain your medical information electronically, you may obtain an electronic copy of the information or ask us to send it to a person or organization that you identify. To request to inspect and/or obtain a copy of your medical information. You must submit a written request to our Privacy Officer. If you request a copy (paper or electronic) of your medical information, we may charge you a reasonable, cost-based fee.
•Ask us to correct your medical record. You can ask us to correct health information about you that you think is incomplete or incorrect. We may say "no" to your request, but we'll tell you why in writing within 60 days.
•Confidential communications, You can ask us to contact you in a specific way (for instance home or office phone) or to send mail to a different address for items such as appointment reminders. We will say yes to all reasonable requests.
•Limits on what we use and share You can ask us NOT to share certain health information for treatment, payment, or operations. We are not required to agree to your request and if it affects your care, we may say no.
•Accounting of disclosures ,You can ask for a list (accounting) of the times we have shared your health information for the prior six years. We will include all disclosures, except those about treatment, payment, and operations. We will provide one accounting for free, but may charge a reasonable. cost-based fee if you ask for another within 12 months.

•Privacy Notice. You can ask and receive a paper copy of this notice at any time.
•Complaint. You can file a complaint if you feel we have violated your rights, with the office at the address below. or you with the Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, SW,Room 509F HHH Bldg., Washington, D.C. 20201, calling 1-877-696-6775, or by visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

In these cases we will never share your information unless given written permission: Marketing purposes. fundraising, and the sale of information.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may, without prior consent. use or disclose protected health information to carry out treatment, payment, or healthcare operations in the following circumstances:

•If we are required by law to treat you, and we attempt to obtain such consent but are unable to contain such consent: or
•If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you. and we determine that. in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances.

State Law

We will not use or share your information if state law prohibits it. Some states have laws that are stricter than the federal privacy regulations, such as laws protecting HIV/AIDS information or mental health information. If a state law applies to us and is stricter or places limits on the ways we can use or share your health information, we will follow the state law. If you would like to know more about any applicable state laws, please ask our Privacy Officer.

We are required by law to maintain the privacy and security of your protected health information. We will promptly let you know if a breach occurs that may have compromised the privacy and security of your information. This notice is effective as of 2003 and we are required to abide by the terms of the Notice of Privacy Practices. We will not share your information other than described in here unless we receive written authorization. We can change the terms of notice, and any new notices will be available upon request, in our office, and on our website.

If you have any questions or want more information about this notice or how to exercise your health information rights, you may contact our Privacy Officer, Thomas Southam by mail at: 3150 S.Gilbert Rd. Ste1 Chandler, AZ 85286 or telephone at 480-659-7800. You have the right to exercise any of the actions in the above document. and the Privacy Officer will guide you through the process.

I have read and understand the above information.