Click the button below to fill out New Patient Forms online.
**For your convenience and to minimize your wait time in our office, we ask that you complete the New Patient Forms online at least one day before your appointment. There is a 30-minute time limit for completing the paperwork online. If you get an error message, the process did not work. You may try again or print out the forms.**
The information we gather helps us to determine the course of your treatment. We have to know about allergies, sensitivity to anesthetics, long-term medications, etc.
If you’re unable to complete the forms online, you can access them for download at the bottom of this page.
Thank you for entrusting us with your dental care needs. Our goal is to provide you with the quality care in a friendly, comfortable atmosphere and in the most timely manner possible. This information is designed to guide you through the rapidly changing worlds of medicine and insurance plans. Please read carefully and sign at the bottom of the page indicating your understanding of our policies and procedures.
We believe your time is as valuable as ours. We do not overbook patients except in cases of emergency and we do our best to stay on schedule to avoid any delays to you. Please assist us in our efforts to stay on time in the following ways. Please arrive on time for your appointment. If you are more than 15 minutes late it may be necessary to reschedule your appointment for a later time.
If you are a new patient, please arrive 15 minutes early to allow for time to fill out necessary medical and insurance information. If paperwork was mailed to you in advance, please bring the completed forms as well as your insurance card and driver’s license to the office on the day of your appointment. Our receptionists are required to keep patient demographic information as up to date as possible. Please understand that we may ask you for any change of address or phone number on subsequent visits. This information helps us to better serve you.
Please realize that it is each individual’s responsibility to keep track of appointments made. If you need to cancel an appointment, please give us 24 hours notice so that we may schedule another patient in the time slot reserved for you. On occasion you may not receive a reminder call, however, please realize it is each individual’s responsibility to keep track of appointments made. If you do not cancel your appointment 24 hours in advance, a $35.00 fee may be charged (except in cases of emergencies or illness) and is payable prior to future visits.
PAYMENT FOR ANY PROCEDURE OR PORTION OF A CHARGE NOT COVERED BY INSURANCE WILL BE COLLECTED AT THE TIME OF YOUR APPOINTMENT.
It is the ultimate responsibility of the patient to understand his/her insurance coverage. Our staff cannot call your insurance company at the time of your visit to obtain information about your benefits. Insurance policies may change and/or insurance company representatives to not always give us correct or consistent information. In the event of denials, errors, or non-covered services, the patient is responsible for all services rendered. As a courtesy to you, we will file your primary insurance claims. Patients are responsible for their co-payments and/or deductibles at the time services are rendered. If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency or lawyer, you agree to pay any and all of the collections costs, lawyer fees and court cost incurred.
We thank you for understanding our financial policies. This has become necessary in order to continue to accept insurance plans without having patients pay the balance up front and then wait for reimbursement from their insurance company. Our goal is to make your visit with us pleasant and professional. If you have any questions, please feel free to ask our staff for assistance. Thank you again for choosing us for your care.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and disclosures to carry out treatment, payment, and health care operations
Treatment- This practice may use or disclose your protected health information in consultation between health care providers relating to your treatment or for your referral to another health care provider for your treatment.
Payment- This practice may use or disclose your protected health information for billing, claims management, collection activities, or obtaining payment.
Health care Operation- This practice may use or disclose your protected health information for reviewing the competence or qualifications of health care professionals, or for conducting training programs in which students, trainees, or practitioners participate. This practice may use or disclose your protected health information for accreditation, certification, licensing, or credentialing activities. This practice may use or disclosure your protected health information to our business associates who participate in our healthcare operations. These disclosures will only be made after we have satisfactory assurances in the form of a Business Associates Agreement from the business associate. These assurances will include their agreement to comply with the HIPAA rules and the compliance of any subcontractor with which they do business.
The following uses or disclosures require a valid authorization as defined by the HIPAA standards.
Uses or Disclosures for Psychotherapy Notes- Not applicable to this practice
Uses or Disclosures for Marketing Purposes- Not applicable to this practice
Disclosures for a Sale of Protected Health Information- This practice will require an authorization for any disclosures that would constitute a sale of protected health information.
For any other use or disclosure you wish us to make, you can give us a written, valid authorization. Your authorization must have specific instructions for the use and disclosure you want us to make. You will have the right to revoke the authorization in writing at any time before the information is used or disclosed.
Uses or disclosures requiring an opportunity for the individual to agree or object
For disclosures to others involved with your health care or payment, we will inform you in advance and give you the opportunity to agree or object. These disclosures will be limited to the information necessary to help with your health care or payment. These disclosures will only be made if you do not object.
Uses and disclosures for which an authorization or opportunity to agree or object is not required
The following uses or disclosures do not require an authorization or the opportunity for you to agree or object.
Uses and disclosures required by law- This practice may use or disclose protected health information to the extent required by law. The use or disclosure will comply with and be limited to the relevant requirements of such law.
Uses and disclosures for public health activities- This practice may use or disclose protected health information for the purpose of preventing or controlling disease, injury, or disability, including, but not limited to, the reporting of disease, injury, and vital events such as birth or death.
Disclosures about victims of abuse, neglect or domestic violence- This practice may disclose protected health information about an individual whom this practice reasonably believes to be a victim of abuse, neglect, or domestic violence.
Uses and disclosures for health oversight activities- This practice may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations, inspections, licensure, or disciplinary actions.
Disclosures for judicial and administrative proceedings- This practice may, in response to an order of a court or administrative tribunal, provide only the protected health information expressly authorized by such order or a subpoena.
Disclosures for law enforcement purposes- This practice may disclose protected health information as required by law including laws that require the reporting of certain types of wounds or other physical injuries.
Uses and disclosures about decedents- This practice may disclose protected health information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. We may disclose protected health information to a funeral director, as authorized by law, to carry out their duties. This disclosure will be made in reasonable anticipation of death.
Uses and disclosures for cadaveric organ, eye or tissue donation purposes- This practice may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
Uses and disclosures for research purposes- This practice may use or disclose protected health information for research, when the research has been approved by an institutional review board or privacy board, to protect your protected health information.
Uses and disclosures to avert a serious threat to health or safety- This practice may, consistent with applicable law and standards of ethical conduct, use or disclose protected health information, in good faith, if we believe the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Uses and disclosures for specialized government-This practice may use and disclose the protected health information of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission, if the appropriate military authority has published by notice in the Federal Register.
Disclosures for workers’ compensation- This practice may disclose protected health information as authorized by and to the extent necessary, to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
The following information describes your rights under the HIPAA Standards. This practice requires that all requests for the various rights be made in writing and we will provide our decision on your request in writing. You should be aware that there may be some situations when there could be limitations placed on your rights. We are required to permit you to request these rights, but we are not required to agree to your request, except as discussed in the Right of Restriction section.
Right of an individual to request a restriction of uses and disclosures
This practice will permit an individual to request that we restrict uses or disclosures of protected health information about the individual to carry out treatment, payment, or health care operations or to others involved in your care or in payment. We will consider these requests, but we are not required to agree to them, except as discussed in the next section.
Under your right of restriction, you may restrict certain disclosures of protected health information to a health plan for payment or healthcare operation, where payment in full is made out of pocket for a healthcare item or service.
This practice will permit an individual to request and will accommodate reasonable requests to receive communications of protected health information from our practice by alternative means or at an alternative location.
Access of individuals to protected health information
An individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set except as prohibited by state or federal law or certain other exemption. Your access may be provided in electronic form if producible at your request or in another form or format. As permitted by state and federal law, we may charge you a reasonable cost based fee for a copy of your record. Questions about the fee should be addressed to our Privacy Officer at the phone number listed at the end of this document.
An individual has the right to ask to have this practice amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set.
Accounting of disclosures of protected health information
An individual has a right to receive an accounting of disclosures of protected health information made by this practice in the past six years but not before April 14, 2003. The accounting will not include disclosures made for treatment, payment, or operations, as well as authorized disclosures or disclosures made for which you had an opportunity to agree or object. You may receive one free accounting in a 12 month period. There will a reasonable cost based fee for additional requests.
An individual has the right to and will receive a notification of any breach of their unsecured protected health information as defined by the Breach Notification Rule. We will fulfill our obligation to provide notice in accordance to HIPAA standards.
You have a right to a copy of this notice. Even if you agreed to receive an electronic copy, you may request and receive a paper copy.
This practice is required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information.
This practice is required to abide by the terms of the notice currently in effect.
This practice is required to notify you of any change in a privacy practice that is described in the notice to protected health information that we created or received prior to issuing a revised notice. We reserve the right to change the terms of our notice and to make the new notice provisions effective for all protected health information that we maintain. Revised Notices with be available and posted at our offices(s) and posted on our web site, if applicable.
If at any time you feel we have violated your HIPAA rights, please contact our Privacy Officer or the Secretary of Health and Human Services. This practice will not retaliate against any individual for filing a complaint.
You have the right to file a complaint with our Privacy Officer at the address and phone number at the top of this notice, or with the Office of Civil Rights, US Department of Health and Human Services, 61 Forsyth St., SW, Suite 3B70, Atlanta, GA 30323.
Effective Date of the Notice is 10-01-13.
The following information applies to your giving consent for Internet communication. You will be asked to sign this form during your first visit to our office.
I grant my permission to Southlake Family Dentistry to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or any other need to deactivate my ID due to security concerns.
I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make sure of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf.
I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
I have read the information above regarding the secured uploading of patient information to the website for the dental practice, and grant the dental practice permission to securely upload my patient information to the website.
If you’re not able to fill the forms out online, we’ve included them below. Click on the links to download and print out these forms at home, where you can fill them out at your leisure and bring them with you to your first visit.