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Patient Information
Primary Insurance Information
Secondary Insurance Information
Medical History
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Financial Arrangements

Optional Payment Terms:
· Full Pay Cash Discount: We offer a 5% accounting courtesy for all treatment over $500 that is paid in
full prior to the commencement of treatment.
· Full Pay Credit: We accept full or partial payment by Visa, MasterCard, American Express, or Discover.
· Term Loan: By arrangement with Care Credit, we can offer our patients, upon approval, an interest-free
loan (up to 12 months) with no down payment, no annual fee, and no prepayment penalty. Ask for an
application.

There will be a fee for any additional procedure(s) NOT included in the original treatment plan.

Payment Policies
To maintain the practice operation and to prevent potential misunderstanding, we ask patients to accept and
adhere to financial arrangements regarding their dental treatment. Payments are expected at the time services are
rendered. We accept cash, check, check cards, and all major credit cards. Any treatment estimated above $300.00
must be accompanied by a specific financial arrangement.

Dental Insurance
We are happy to assist you in filing the necessary forms to help you receive the full benefits of your coverage;
however, we can make no guarantee of any estimated coverage or payment. Because the insurance policy is an
agreement between you and your insurance company, we ask that all patients be responsible directly for all
charges. Please know we will do everything possible to see that you receive the full benefits of your policy.

I understand that if my account has been turned over to a third party collection agency for non-payment, there
will be a collection fee added to my bill of thirty five percent (35%), pursuant to Georgia Statutory Law
“O.C.G.A.-13-1-148.”

Patients are responsible for the full amount of their bill.

Broken Appointments
Your appointment is time that has been reserved especially for you and we strongly encourage all patients to
keep their appointments. If you must change your appointment, we require a minimum of 48 hours' notice to
avoid a cancellation fee.
Dental Wellness Survey

Our office is unique and unlike any dental office you have ever been to. Your upcoming visit is an important step towards your dental wellness. Please answer the following questions so that we may better serve you.
Our goal is to help you take care of your teeth, smile, and mouth at a level that is right for you. In our practice,
we believe that the level of care that you want is your choice. We will help you thoroughly understand your
dental choices so you can make the best possible decision. Your first choice is how you would like us to work
with you. Please consider the following guidelines for care so that we can best meet your goals. Which of the
following levels of care do you prefer?

Level 5: Optimal Dentistry
Just like complete dentistry patients, patients at this level are focused on long-term dental health and disease
prevention, but they also want their teeth and smile to look great. Patients at this level are interested in treatment
options to correct all dental concerns for lifelong optimal function and appearance. For some of these patients
enhancing their appearance with a beautiful new smile is very important. Optimal dentistry patients are
dedicated to do more then what their insurance allows in a year.

Level 4: Complete Dentistry
Complete dentistry patients are concerned about the current conditions in their mouth, the causes of dental
disease, and their long-term health. They want to know their full treatment options so they can become and
remain as healthy as they can be, thereby minimizing their long-term dental costs. These patients often choose a
step-by-step master plan focused on restoring their health, combined with prevention and regular care to achieve
steady long-term dental health and an improved appearance to their smile over time. Complete dentistry patients
are dedicated to do more then what their insurance allows in a year.

Level 3: Proactive Care
Patients at this level seek treatment for existing concerns just like remedial care patients, but they are also
concerned about conditions that may create problems in the near future. These patients generally want to
maintain the health of each tooth at a basic level, so they also do what they can to prevent new concerns from
developing. When treatment is recommended proactive care patients usually prioritize their treatment to manage
their costs, but still take care of things soon enough so that known concerns are less likely to develop into major
problems. Proactive care patients are usually interested in maximizing what their insurance allows in a year.

Level 2: Remedial Care
Patients at this level choose treatment for obvious problems such as broken or cracked teeth, cavities, sensitivity,
discomfort, or concerns that are creating issues in the mouth right now. Remedial care patients are usually not
focused on taking steps to prevent new concerns or improve their health over time. They only want to deal with
concerns that have already developed into conditions that require treatment to remove existing disease or repair
the teeth back to the most basic level of health. Remedial care patients are usually only interested in doing
treatment that their insurance allows in a year.

Level 1: Urgent Care
Patients at this level choose treatment only when they experience a crisis such as pain, swelling, or bleeding that
requires immediate treatment. Urgent care patients are generally not focused on taking steps to ensure future
urgencies do not occur. They come in when they know they have a major problem to deal with and the condition
has developed to a point of urgency in order to control pain or save the tooth.

It is not uncommon for people to begin at one level and progress to higher levels when they are ready. We are
here to help you discover what is right for you so your teeth, smile, and mouth remain as healthy as they can be
or life based on your goals.
Office Procedures

1. Phone Confirmations: It our procedure that you call 24 hours in advance to cancel your appointment or there will be a charge of $55.

2. Verbal Authorization: It is our office procedure to get verbal authorization from all new patients to confirm appointments and leave messages if patient is not available. Also, patient must call 24 hours in advance to cancel appointments. It is also our procedure that we get your insurance information so we can confirm the status of your insurance and get prior authorization for treatment as needed.

3. Reminders: It is our office procedure that we mail reminder postcards that say when your next hygiene appointment is scheduled or that remind you when you are due for your next hygiene appointment.
4. Personal representative: I authorize the following person(s) to be my personal representative(s), which means the doctor and staff may speak freely to the named personal representative regarding all my Protected Health Information, Medical and Treatment matters, and Billing.
5. Child's representative: I authorize the following named person/persons to authorize medical treatment for my named children. The Doctor and staff may speak freely regarding my child/children’s protected health information, medical treatment matters and billing. I understand that I am still responsible for the billing.
6. Authorization for treatment: I authorize this facility to examine and provide medical treatment. I assume full responsibility for any balance due. I authorize my insurance company to pay by check made out directly to this facility. I authorize this facility to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand it is my responsibility to know all rules and restrictions of my insurance policy, to know which hospital, emergency rooms, laboratories, x-ray departments and specialists and specialist providers which are assigned to me according to my insurance policy rule. It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each
transaction.

7. Privacy: Our office is HIPAA-compliant and the staff has been trained in the HIPAA Privacy Act. We will do everything we can to protect your Patient Health information. However, our office was designed before the HIPAA Law so please be respectful of other patients’ privacy.

I agree to all of the above office procedures of this facility, and give my authorization to all of the above procedures.
NOTICE OF PRIVACY PRACTICES

Effective Date: Jan 1, 2014
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.

If you have any questions about this Notice of Privacy Practices (‘Notice’), please contact:
Privacy Officer Stephanie D. Barnes, RDH
Phone Number: 912-748-8585

Section A: Who Will Follow This Notice?
This Notice describes Godley Station Dental (hereafter referred to as ‘Provider’) Privacy Practices and
that of:

Any workforce member authorized to create medical information referred to as Protected Health
Information (PHI) which may be used for purposes such as Treatment, Payment and Healthcare
Operations. These workforce members may include:

 All departments and units of the Provider.
 Any member of a volunteer group.
 All employees, staff and other Provider personnel.
 Any entity providing services under the Provider's direction and control will follow the terms of
this notice. In addition, these entities, sites and locations may share medical information with
each other for Treatment, Payment or Healthcare Operational purposes described in this Notice.

Section B: Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to
protecting medical information about you. We create a record of the care and services you receive at the
Provider. We need this record to provide you with quality care and to comply with certain legal
requirements. This Notice applies to all of the records of your care generated or maintained by the
Provider, whether made by Provider personnel or your personal doctor.

This Notice will tell you about the ways in which we may use and disclose medical information about
you. We also describe your rights and certain obligations we have regarding the use and disclosure of
medical information.

We are required by law to:
 Make sure that medical information that identifies you is kept private;
 Give you this Notice of our legal duties and privacy practices with respect to medical information
about you; and
 Follow the terms of the Notice that is currently in effect.

Section C: How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information. For each
category of uses or disclosures we will explain what we mean and try to give some examples. Not every
use or disclosure in a category will be listed. However, all of the ways we are permitted to use and
disclose information will fall within one of the categories.

Treatment. We may use medical information about you to provide you with medical treatment or
services. We may disclose medical information about you to doctors, dental hygienist, dental
assistants, nurses, technicians, health care students, or other Provider personnel who are
involved in taking care of you at the Provider. For example, a doctor treating you for a broken leg
may need to know if you have diabetes because diabetes may slow the healing process. In
addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for
appropriate meals. Different departments of the Provider also may share medical information
about you in order to coordinate different items, such as prescriptions, lab work and x-rays. We
also may disclose medical information about you to people outside the Provider who may be
involved in your medical care after you leave the Provider.

Payment. We may use and disclose medical information about you so that the treatment and
services you receive at the Provider may be billed and payment may be collected from you, an
insurance company or a third party. For example, we may need to give your health plan
information about surgery you received at the Provider so your health plan will pay us or
reimburse you for the procedure. We may also tell your health plan about a prescribed treatment
to obtain prior approval or to determine whether your plan will cover the treatment.

Healthcare Operations. We may use and disclose medical information about you for Provider
operations. These uses and disclosures are necessary to run the Provider and make sure that all
of our patients receive quality care. For example, we may use medical information to review our
treatment and services and to evaluate the performance of our staff in caring for you. We may
also combine medical information about many Provider patients to decide what additional
services the Provider should offer, what services are not needed, and whether certain new
treatments are effective. We may also disclose information to doctors, nurses, technicians,
health care students, and other Provider personnel for review and learning purposes. We may
also combine the medical information we have with medical information from other Providers to
compare how we are doing and see where we can make improvements in the care and services
we offer. We may remove information that identifies you from this set of medical information so
others may use it to study health care and health care delivery without learning a patient's
identity.

Appointment Reminders. We may use and disclose medical information to contact you as a
reminder that you have an appointment for treatment or medical care at the Provider.

Treatment Alternatives. We may use and disclose medical information to tell you about or
recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information to tell
you about health-related benefits or services that may be of interest to you.

Fundraising Activities. We may use information about you to contact you in an effort to raise
money for the Provider and its operations. We may disclose information to a foundation related
to the Provider so that the foundation may contact you about raising money for the Provider. We
only would release contact information, such as your name, address and phone number and the
dates you received treatment or services at the Provider. If you do not want the Provider to
contact you for fundraising efforts, you must notify us in writing and you will be given the
opportunity to ‘Opt-out’ of these communications.

Authorizations Required
We will not use your protected health information for any purposes not specifically allowed by
Federal or State laws or regulations without your written authorization, this includes uses of your
PHI for marketing or sales activities.

Emergencies. We may use or disclose your medical information if you need emergency
treatment or if we are required by law to treat you but are unable to obtain your consent. If this
happens, we will try to obtain your consent as soon as we reasonably can after we treat you.

Psychotherapy Notes
Psychotherapy notes are accorded strict protections under several laws and regulations.
Therefore, we will disclosure psychotherapy notes only upon your written authorization with
limited exceptions.

Communication Barriers. We may use and disclose your health information if we are unable to
obtain your consent because of substantial communication barriers, and we believe you would
want us to treat you if we could communicate with you.

Provider Directory. We may include certain limited information about you in the Provider
directory while you are a patient at the Provider. This information may include your name,
location in the Provider, your general condition (e.g., fair, stable, etc.) and your religious
affiliation. The directory information, except for your religious affiliation, may also be released to
people who ask for you by name. Your religious affiliation may be given to a member of the
clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family,
friends and clergy can visit you in the Provider and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. We may release medical
information about you to a friend or family member who is involved in your medical care and we
may also give information to someone who helps pay for your care, unless you object in writing
and ask us not to provide this information to specific individuals. In addition, we may disclose
medical information about you to an entity assisting in a disaster relief effort so that your family
can be notified about your condition, status and location.

Research. Under certain circumstances, we may use and disclose medical information about
you for research purposes. For example, a research project may involve comparing the health
and recovery of all patients who received one medication to those who received another, for the
same condition. All research projects, however, are subject to a special approval process. This
process evaluates a proposed research project and its use of medical information, trying to
balance the research needs with patients' need for privacy of their medical information. Before 
we use or disclose medical information for research, the project will have been approved through
this research approval process, but we may, however, disclose medical information about you to
people preparing to conduct a research project, for example, to help them look for patients with
specific medical needs, so long as the medical information they review does not leave the
Provider. We will almost always generally ask for your specific permission if the researcher will
have access to your name, address or other information that reveals who you are, or will be
involved in your care at the Provider.

As Required By Law. We will disclose medical information about you when required to do so by
federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information
about you when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would only be to someone able
to help prevent the threat.

E-mail Use.
E-mail will only be used following this Organization’s current policies and practices and with your
permission. The use of secured, encrypted e-mail is encouraged.

Section D: Special Situations
Organ and Tissue Donation. If you are an organ donor, we may release medical information to
organizations that handle organ procurement or organ, eye or tissue transplantation or to an
organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release medical
information about you as required by military command authorities. We may also release medical
information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release medical information about you for workers'
compensation or similar programs.

Public Health Risks. We may disclose medical information about you for public health activities.
These activities generally include the following:
o to prevent or control disease, injury or disability;
o to report births and deaths;
o to report child abuse or neglect;
o to report reactions to medications or problems with products;
o to notify people of recalls of products they may be using;
o to notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; and
o to notify the appropriate government authority if we believe a patient has been the victim
of abuse, neglect or domestic violence. We will only make this disclosure if you agree or
when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency
for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order. We may also disclose
medical information about you in response to a subpoena, discovery request, or other lawful
process by someone else involved in the dispute, but only if efforts have been made to tell you
about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information if asked to do so by a law enforcement
official:
o in response to a court order, subpoena, warrant, summons or similar process;
o to identify or locate a suspect, fugitive, material witness, or missing person;
o about the victim of a crime if, under certain limited circumstances, we are unable to obtain
the person's agreement;
o about a death we believe may be the result of criminal conduct;
o about criminal conduct at the Provider; and
o in emergency circumstances, to report a crime; the location of the crime or victims; or the
identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release medical information to
a coroner or medical examiner. This may be necessary, for example, to identify a deceased
person or determine the cause of death. We may also release medical information about patients
of the Provider to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you
to authorized federal officials for intelligence, counterintelligence, and other national security
activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about
you to authorized federal officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release medical information about you to the correctional institution
or law enforcement official. This release would be necessary for the institution to provide you
with health care, to protect your health and safety or the health and safety of others, or for the
safety and security of the correctional institution.

Section E: Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:

Right to Access, Inspect and Copy. You have the right to access, inspect and copy the
medical information that may be used to make decisions about your care, with a few exceptions.
Usually, this includes medical and billing records, but may not include psychotherapy notes. If
you request a copy of the information, we may charge a fee for the costs of copying, mailing or
other supplies associated with your request.

 We may deny your request to inspect and copy medical information in certain very limited
circumstances. If you are denied access to medical information, in some cases, you may request
that the denial be reviewed. Another licensed health care professional chosen by the Provider
will review your request and the denial. The person conducting the review will not be the person
who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for the Provider. In addition, you must
provide a reason that supports your request.

 We may deny your request for an amendment if it is not in writing or does not include a reason to
support the request. In addition, we may deny your request if you ask us to amend information
that:
o Was not created by us, unless the person or entity that created the information is no
longer available to make the amendment;
o Is not part of the medical information kept by or for the Provider;
o Is not part of the information which you would be permitted to inspect and copy; or
o Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an ‘Accounting of
Disclosures’. This is a list of the disclosures we made of medical information about you. Your
request must state a time period which may not be longer than six years and may not include
dates before April 14, 2003. Your request should indicate in what form you want the accounting
(for example, on paper or electronically, if available). The first accounting you request within a 12
month period will be complimentary. For additional lists, we may charge you for the costs of
providing the list. We will notify you of the cost involved and you may choose to withdraw or
modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the
medical information we use or disclose about you for payment or healthcare operations. You also
have the right to request a limit on the medical information we disclose about you to someone
who is involved in your care or the payment for your care, like a family member or friend. For
example, you could ask that we not use or disclose information about a surgery you had. In your
request, you must tell us what information you want to limit, whether you want to limit our use,
disclosure or both, and to whom you want the limits to apply (for example, disclosures to your
spouse). We are not required to agree to these types of request. We will not comply with any
requests to restrict use or access of your medical information for treatment purposes.

You also have the right to restrict use and disclosure of your medical information about a service
or item for which you have paid out of pocket, for payment (i.e. health plans) and operational (but
not treatment) purposes, if you have completely paid your bill for this item or service. We will not
accept your request for this type of restriction until you have completely paid your bill (zero
balance) for this item or service. We are not required to notify other healthcare providers of these
restrictions, that is your responsibility.

Right to Receive Notice of a Breach. We are required to notify you by first class mail or by
email (if you have indicated a preference to receive information by email), of any breaches of
Unsecured Protected Health Information as soon as possible, but in any event, no later than 60
days following the discovery of the breach. “Unsecured Protected Health Information” is
information that is not secured through the use of a technology or methodology identified by the
Secretary of the U.S. Department of Health and Human Services to render the Protected Health
Information unusable, unreadable, and undecipherable to unauthorized users. The notice is
required to include the following information:
o a brief description of the breach, including the date of the breach and the date of its
discovery, if known;
o a description of the type of Unsecured Protected Health Information involved in the
breach;
o steps you should take to protect yourself from potential harm resulting from the breach;
o a brief description of actions we are taking to investigate the breach, mitigate losses, and
protect against further breaches;
o contact information, including a toll-free telephone number, e-mail address, Web site or
postal address to permit you to ask questions or obtain additional Information.

In the event the breach involves 10 or more patients whose contact information is out of date we
will post a notice of the breach on the home page of our website or in a major print or broadcast
media. If the breach involves more than 500 patients in the state or jurisdiction, we will send
notices to prominent media outlets. If the breach involves more than 500 patients, we are
required to immediately notify the Secretary. We also are required to submit an annual report to
the Secretary of a breach that involved less than 500 patients during the year and will maintain a
written log of breaches involving less than 500 patients.

Right to Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or hard copy or e-mail. We will not ask
you the reason for your request. We will accommodate all reasonable requests. Your request
must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You
may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this
Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy
of this Notice at our website godleystationdental.com

To exercise the above rights, please contact the individual listed at the top of this Notice to obtain a copy
of the relevant form you will need to complete to make your request.

Section F: Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice
effective for medical information we already have about you as well as any information we receive in the
future. We will post a copy of the current Notice. The Notice will contain on the first page, in the top right
hand corner, the effective date. In addition, each time you register at or are admitted to the Provider for
treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current
Notice in effect.

Section G: Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Provider or with
the Secretary of the Department of Health and Human Services;
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

To file a complaint with the Provider, contact the individual listed on the first page of this Notice. All
complaints must be submitted in writing. You will not be penalized for filing a complaint.

Section H: Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us
will be made only with your written permission. If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about you for the reasons covered by
your written authorization. You understand that we are unable to take back any disclosures we have
already made with your permission, and that we are required to retain our records of the care that we
provided to you.

Section I: Organized Healthcare Arrangement
The Provider, the independent contractor members of its Medical Staff (including your physician), and
other healthcare providers affiliated with the Provider have agreed, as permitted by law, to share your
health information among themselves for purposes of treatment, payment or health care operations.
This enables us to better address your healthcare needs.

Revision Date: March 03, 2013, to be compliant with HIPAA Omnibus Privacy Rules.
Original Effective Date: April 14, 2003.