New Patient Form

Responsible Party

Dental History

Health Information
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions

Women

Authorization and Release
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that I am financially responsible for all charges whether or not paid by insurance. Refusal to pay any and all outstanding balances could result in collection proceedings after 90 days delinquent. I authorize the release of any information, including the diagnosis and records of treatment/examination rendered, to my insurance company and other healthcare providers as necessary.

Photograph Release
In our office, photographs may be taken of our patients for aid in determining proper diagnosis and to help visualize with the appropriate treatment options. I hereby authorize JBH Smiles to take photographs of my face, jaws, and teeth. I understand that the photographs will be used in a record of my care and may be used for research, publications, or educational purposes.

Cancellation Policy
We request two-business day advance notice for any change or cancellation of your appointment. This allows us the time we reserve especially for you in our schedule to be filled by another patient who may have been waiting for this appointment time. We do, however, understand that illness and other emergencies occur and we do make exceptions for those rare instances. A fee may be charged to your account for not adhering to this policy. For an appointment scheduled with our hygienists, the fee is $75.00. Appointments scheduled with the doctor will be charged a fee of $100.00.

Our Policy of Care and Payment
Payment is due at the time of treatment. As a courtesy to our patients, we will file for the estimated portion of payment provided by your primary insurance company, our office does not file secondary insurance. Any co-payment amount or non-covered portion is due at the time of treatment. Dental insurance is a contract between the patient and the insurance carrier, not the dental office. The insured patient is ultimately responsible for all costs of dental treatment. We accept cash, checks, Visa, Mastercard, Discover, and American Express. We also offer flexible payment plans with CareCredit, which allows you to start treatment today and spread payments over time.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office: (770) 952-5200

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the
Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

​​​​​​​I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Please Sign: I understand and agree to all of the above

VERY IMPORTANT: When we send you, your dentist, or any other healthcare professional an email, or you send us an email, the information sent is not encrypted. That means a third party may be able to access the information and read it since it is transmitted over the Internet. HIPAA stands for the Health Insurance Portability and Accountability Act HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information Information stored on our computers is encrypted. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.

Email is a very popular and convenient way to communicate for a lot of people. In their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

By signing this document, you are giving us permission to send such information over the internet, unencrypted.

​​​​​​​If you would like more information on the HIPAA act: https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf