CONSENT FOR TREATMENT

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3 Thank yu fr chsing 2 nd Street Dental, LLC as yur dental prvider. We are cmmitted t yur treatment being successful. Please understand that payment f yur fees is cnsidered part f yur treatments. The fllwing is a statement f ur Financial Plicy, which we ask that yu read and agree t sign prir t treatment. *All patients must cmplete the Ntice f Privacy Practices, Patient Infrmatin Frm, HIPPA frm, and Medical Health Histry Frms befre seeing the dctr. *Please be aware that patients nly are allwed in the peratry. This includes children. I understand this. (Please sign). *Missed appintments- It is ffice plicy t call and cnfirm dental appintments the business day prir t the appintment. Thus, unless cancelled at least 24 hurs in advance, we charge fr missed appintments. Please help us t better serve yu and thers by keeping a scheduled appintment r by letting us knw in advance if that appintment needs t be changed. Please be aware that cnfirmed n call/n shw appintments are grunds fr dismissal frm the practice. I have read and understand this. (Please initial) We expect payment rendered at time f services. As a curtesy t yu, we will file yur insurance claim with yur prvider and they will reimburse yu. It is imprtant that yu are aware that having insurance is nt a guaranteed frm f payment. Please realize that sme and perhaps all f the services prvided may nt be cvered. Frms f payment include cash, debit card, Visa, MasterCard, and CITI Health Care Card- subject t credit apprval. CONSENT FOR TREATMENT I hereby authrize the dctr r designated staff t take x-rays, study mdels, phtgraphs, and any ther diagnstic aids deemed apprpriate t make a thrugh diagnsis f (Name f Patient) s dental needs. 1) Upn such diagnsis, I authrize the dctr t perfrm all recmmended treatment mutually agreed upn by me and t emply such assistance as required t prvide prper care. 2) I agree t the use f anesthetics, sedatives, and ther medicatins as necessary. I fully understand that using anesthetic agents embdies certain risks. I understand that I can ask fr a cmplete recital f any pssible cmplicatins if I s chse. 3) I give cnsent t the dctr s r designated staff s use and disclsure f any ral, written, r electrnic health recrds that are individually identifiable as mine fr the purpse f carrying ur my treatment, payment, and healthcare peratins. I understand that nly the minimum amunt f infrmatin necessary t prvide quality care will be used r disclsed and that a ntice fully utlining the prtectins f my persnal health infrmatin is available. 4) I, the undersigned patient/guardian, agree t pay fr all services that are rendered t myself r the patient immediately upn demand by 2 nd Street Dental, LLC. I further agree that in the event f nn-payment t 2 nd Street Dental, LLC f any amunts under this agreement, I will pay interest at the rate f 15% n all amunts due, a late fee f $25 per mnth until paid in full, and all attrney fees and curt csts that may be incurred. I further agree that in the event that 2 nd Street Dental, LLC assigns this accunt t an agent fr cllectins, I prmise t pay an additinal cllectin fee f 40% f any unpaid balance. I have read this agreement and understand its prvisins. Patient f Parent/Guardian Signature Relatinship t Patient Date Page 1 f 2

4 PATIENT CONSENT FORM I understand that, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPPA), I have certain rights t privacy regarding my prtected health infrmatin. I understand that this infrmatin can and will be used t: Cnduct, plan, and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly. Obtain payment frm third-party payers. Cnduct nrmal healthcare peratins such as quality assessments and physician certificatins. I have been infrmed by yur f yur Ntice f Privacy Practices cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I have been given the right t review such Ntice f Privacy Practices prir t signing this cnsent. I understand that this rganizatin has the right t change its Ntice f Privacy Practices frm time t time and that I may cntact this rganizatin at any time at the address belw t btain a current cpy f the Ntice f privacy Practices. I understand that I may request in writing that yu restrict hw my private infrmatin is used r disclsed t carry ut treatment, payment, healthcare peratins. I als understand yu are nt required t agree t my requested restrictins, but if yu d agree then yu are bund t abide by such restrictins. I understand that I may revke this cnsent in writing at any time, except t the extent that yu have taken actin relying n this cnsent. Patient Name: Signature: Relatinship t Patient: Date: 2 nd Street Dental, LLC 2546 E. 2 nd St. Suite 300 Casper, WY Page 2 f 2

5 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW THIS FORM CAREFULLY, THE PRIVACE OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law t maintain the privcay f yur health infrmatin.we are als required t give yu this Ntice abut ur privacy practices, ur legal duties, and yur rights cncerning yur health infrmatin. We must fllw the privacy practices that are described in this Ntice while it is in effect. This Ntice takes effect Octber 8, 2012, and will remain in effect until we replace it. We reserve the right t change ur privacy practices and the terms f this Ntice at any time, prvided such changes are permitted by applicable law. We reserve the right t make the changes in ur privacy practices and the new terms f ur Ntice effective fr all ur health infrmatin that we maintain, including health infrmatin we created r received befre we made the changes. Befre we make a significant change in ur privacy practives, we will change this Ntice and make the new Ntice available upn request. Yu may request a cpy f ur Ntice at any time. Fr mre infrmatin abut ur privacy practices, r fr additinal cpies f the Ntice, please cntact us using the infrmatin listed at the end f this Ntice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclse health infrmatin abut yu fr treatment, payment, and healthcare peratins. Fr example: Treatment: We may use r disclse yur health infrmatin t a physician r ther healthcare prvider prviding treatment t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur healthcare peratins. Healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence r qualificatins f healthcare prfessinals, evaulating practiciner and prvider perfrmance, cnducting training prgrams, accreditatin, certificatin, licensing, r credentialing activities. Yur Authrizatin: In additin t ur use f yur health infrmatin fr treatment, payment, and healthcare peratins, yu may give us written authrizatin t use yur health infrmatin r t disclse it t anyne fr any purpse. If yu give us written authrizatin, yu may revke it in writing at any time. Yur revcatin will nt affect any use f disclsure permitted by yur authrizatin while it was ineffect. Unless yu give us written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this Ntice. T Yur Family and Friends: We must disclse yur health infrmatin t yu as describedin the Patient Rights sectin f this Ntice. We may disclse yur health infrmatin t a family member, friend, r ther persn t the extent necessary t ghelp with yur healthcare r with payment fr yur healthcare, but nl if yu agree that we may d s. Persns Invlved in Care: We may use r disclse health infrmatin t ntify, r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representatice, r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses r disclsures. In the event f yur incapacity r emergency circumstances, we will discluse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn s invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable inferences f yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x-rays, r ther similar frms f health infrmatin. Marketing Health Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Abuse r Neglect: We may disclse yur health infrmatin t apprpriate authrities if we reasnably believe that yu are a pssible victim f abuse, neglect, r dmestic vilence r the pssible victim f ther criwmes. We may disclse yur health infrmatin t the extent necessary t avert a serius threat t yur health r safety r the health r safety f thers. Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t authrized federal fficials the health infrmatin required fr lawful intelligence, cunterintelligence, and ther natinal security activities. We may disclde t crrectinal institutin r law enfrcement fficials having a lawfu lcustdy the prtected health infrmatin f an inmate r patient under certain circumstances. Appintment Reminders: We may use r disclse yur health infrmatin t prvide yu with appintment reminders (such as vic messages, pstcards, r letters). Page 1 f 2

6 PATIENT RIGHTS Access: Yu have the right t lk at r receive yur health infrmatin, with limited exceptins. Yu may request that we prvide cpies in a frmat ther than phtcpies. We will use the frmat yu request unless we cannt practicably d s. (Yu must make a request in writing t btain access t yur health infrmatin. Yu may btain a frm t request access by using the cntact infrmatin listed n this Ntice. Yu may als request access by sending a letter t the address at the end f this Ntice). Disclsure Accunting: If yu request yur t receive cpies f yur health infrmatin mre than nce in a 12-mnth perid, we may charge yu a reasnable, cst-based fee fr respnding t these additinal requests. Restrictins: Yu have the right t request that we place additinal restrictins n ur use r disclsure f yur health infrmatin. We are nt required t agree t these additinal restrictins, but if we d, we will abide by ur agreement (except in an emergency). Alternative Cmmunicatins: Yu have the right t request that we cmmunicate with yu abut yur health infrmatin by alternative means r t alternative lcatins. This request must be made in writing and must specify the alternative means r lcatin, and prvide a satisfactry explanatin f hw payments will be handled under the alternative means r lcatin yu request. Amendment: Yu have the right t request that we amend yur health infrmatin. Yur request must be made in writing and it must explain why the infrmatin shuld be amended. We may deny yur request under certain circumstances. Electrnic Ntice: If yu receive this Ntice n ur website r by electrnic mail, yu are entitled t receive this Ntice in written frm. QUESTIONS AND COMPLAINTS If yu wuld like additinal infrmatin abut ur privacy practices r have questins r cncersn, please call us at (307) If yu are cncerned that we may have vilated yur privacy rights, r yur disagree with a decisin we have made abut yur access t yur health infrmatin r in a respnse t a written request t amend r restrict the use r disclsure f yur health infrmatin r t have us cmmunicate with yu by alternative means r at an alternative lcatin, yu may file a cmplaint in wiritng with ur ffice. Yu may als file a written cmplaint t the U.S. Department f Health and Human Services. We will prvide yu with the address at which t file that cmplaint upn request. We supprt yur right t the privacy f yur health infrmatin. We will nt retaliate in any way if yur chse t file a cmplaint with us r with the U.S. Department f Health and Human Services. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES *Yu May Refuse t Sign This Acknwledgement I hereby acknwledge that I have received a cpy f 2 nd Street Dental, LLC s Privacy Practices. Signature f the Patient r Guardian if under 18: Please Print Name: Date: FOR OFFICE USE ONLY: We attempted t btain acknwledgement f receipt f Our Ntice f Privacy Pracitces, but acknwledgement culd nt be btained due t the fllwing: Individual refused t sign Cmmunicatin barriers prhibited understanding f the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other: (please specify): Page 2 f 2

7 3 Strikes yu re ut PIicy!! We wuld like t thank yu fr chsing ur ffice. We value yur dental treatment and time as we are sure yu d urs. In ur ffice we have a 3 times f missed appintments r n call within 24 hurs; yu will nt be allwed t cntinue yur dental care in ur ffice. Strike 1 = missed appintment /n call = n shw is a warning. Strike 2 = Missed appintment /n call = n shw is a fee $ *** IF YOUR APPOINTMENT IS A 7:00 AM OR 8:00 AM YOU WILL BE CHARGED A $70.00 FEE FOR MISSING!!! Strike 3 Missed appintment /n call = n shw is grunds fr DIMISSAL!! We appreciate the pprtunity t serve yu and yur family, Thank yu, Patient Name printed Patient Signature Date