Welcome
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. lf you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
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Patient Information
Emergency Contact
Referral Information
Primary Insurance
Additional Insurance
Dental History
Medical History
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 appropriate and healthful dental treatment. lf there is any change in my medical status, l will inform the dentist.

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

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Payment is due in full at time of treatment, unless prior arrangements have been approved.
"Deemed Consent" to HIV Testing in Exposure Incidents
As a health care provider we are required by § 32.1 - 45.1 of the Code of Virginia (1950), as amended, to give you the following notice.

1.

If one of our health care professionals, workers, or employees should be directly exposed to your blood or bodily fluids in a manner which may transmit disease, your blood will be tested for the Human Immunodeficiency Virus (HIV/AIDS). A physician or other health care provider will advise you of the test results.

2.

If you should be directly exposed to blood or bodily fluids of one of our health care professionals, workers, or employees in a manner which may transmit disease, that person's blood will be tested for the Human Immunodeficiency Virus (HIV/AIDS). A physician or other health care provider will advise you and that person of the test results.
Patient Financial Policy
Effective 01/14/2019

Welcome to Dr Harre’s office- where our team is proud to provide you superior dental care at reasonable fees.  Please understand that payment of your services is considered part of your treatment.  Because of this, we have adopted a simple financial policy for ALL of our patients.  Please read and sign this policy prior to any treatment being started.

  1. Payment options:

            a. Pay by cash or check prior to or at the time of service.

            b. Pay by credit card prior to or at the time of service (see paragraph 2).

            c. Apply for an extended payment plan (see paragraph 3) prior to starting treatment.

 

  1. Cash, check, Visa, MC, AMEX and Discover are acceptable methods of payment. We offer the option of maintaining a credit card on file for our patients to resolve any outstanding balances not paid by insurance benefits or within 90 days.

    

  1. In the event you are unable to make payment by any of the methods outlined above, you should ask for information about Care Credit to assist you in paying for your dental treatment.  You may be eligible for no interest financing for 6, 12 or 18 months. (This option is not available for patients with Delta Dental insurance.)

 

  1. For treatment that requires a case to be sent to an outside lab for fabrication, we require 50% of the fee to be paid at the time the work is started, with the balance due upon completion of treatment.

 

  1. For treatment that requires 2 hours or longer, we require 50% of the total fee or of your estimated co-pay to be paid prior, as a deposit to reserve your appointment time. If you cancel your appointment after the deposit is made, the credit will remain on your account until your reschedule.

 

  1. Our office will file insurance claims for you at no charge.  However, our office does not guarantee payment or coverage by your insurance company.  Dental insurance usually pays only a portion of your charges and we urge you to be fully aware of the provisions of your dental plan’s policy.  We will not accept responsibility for your insurance company’s delay of payment.

           

  1. Since our time with our patients is very precious to us and lost time is irretrievable, we must charge for broken appointments when we have not been notified at least 24 hours in advance.  Our charge for broken appointments is $25.  Our desire is never to find it necessary to make this charge. Please keep your appointment, we are waiting for you!

 

  1. Any adult that accompanies a minor child is responsible for full payment for that child at the time of service and the adult must remain in the office during treatment.

 

  1. There will be a monthly service charge of 1.5% (18% annually) added to all accounts 30 days overdue. In the rare event that your account becomes past due and is referred to an outside collection agency or attorney, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

 

You will be asked to sign this policy signifying your acknowledgement of and agreement to our financial policies before dental services at John W Harre, DDS, PC are rendered.

 

We look forward to caring for your dental needs.

Acknowledgment of Receipt of Notice of Privacy Practices
You May Refuse to Sign this Acknowledgement
I have received a copy of this office's Notice of Privacy Practices.
Request for Confidential Communications
I request that all communications to me by John W. Harre, DDS, PC and/or his staff be handled in the following manner:
Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for the services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment, disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inference of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, or other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.25 for each page, $25 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

CONTACT INFORMATION

Contact Officer: John W. Harre, DDS, FAGD

Address: 
10 Rock Pointe Ln, Warrenton, VA 20186
Telephone: (540) 349-1220
Fax: (540) 349-8279
E-mail: office@jharredds.com