Patient Forms

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
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SECTION A: PATIENT GIVING CONSENT

PATIENT INFORMATION FORM

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Responsible Party (For Minor Only)

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DENTAL HISTORY

Medical History

FINANCIAL OPTIONS AND FEES FORM

Dr. Scott Byrd

Our commitment is to provide quality dental care to the entire family through exceptional service and the utilization of advanced technology.

PAYMENT IS EXPECTED AT THE TIME THAT SERVICE IS RENDERED

METHODS OF PAYMENT:
1. Cash, Check, Money Order, or Credit Card
2. Dental Insurance (see guidelines below)
3. Care Credit

DENTAL INSURANCE GUIDELINES:
1. We are pleased that you have dental insurance, and our office will assist you in obtaining the maximum benefits specified by your contract. However, your insurance contract is between you, your employer, and the insurance company.

2. As a courtesy to you, we will file your insurance, however, we require that your estimated co-payment and deductible be paid at the time of service.

3. Not all services are a covered benefit in all contracts. Some insurance companies select certain services they will not cover. Any service not covered is your full responsibility.

MCNA & DELTA DENTAL SMILES PATIENTS:
Please be aware that with current OHS rules, a Delta Dental Smiles or MCNA member is responsible for charges for non-covered services, including services received in excess of Medicaid benefit limitations.

By signing this form you agree that you accept responsibility for any and all charges that occur that Medicaid does not cover.

RELATED INFORMATION:
1. Returned checks and balance older than 30 days may be subject to additional collection fees. These fees will be added at the end of each month.

2. In the event that the account is not paid and we refer the account to collection, you will be responsible for all fees incurred for the collection of your bill. (i.e., attorney fees, court costs, and collection agency fees)

3. Due to the rising cost of lab fees, all procedures that require lab involvement will require payment in full by the time we complete your case.

4. Your appointment time has been reserved exclusively for you. Any change in your appointment affects many patients. Please give us 48 hour notice of any changes in your appointment. Failure to do so will result in a $5O fee.


I understand if I have an unpaid balance to Dr. Scott Byrd, DDS and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney's fees if so incurred during collection efforts.

In order for Dr. Scott Byrd, DDS or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Dr. Scott Byrd, DDS and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using prerecorded/ artificial voice message and/or use of an automatic dialing device, as applicable.

I have read and understand the above information. I understand that I am responsible (regardless of my insurance) for any charges incurred from services rendered.

HIPAA RELEASE FORM

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(HIPAA Release Form)

GENERAL CONSENT TO DENTAL TREATMENT DURING COVID-19

Please read before signing:

Thank you for choosing our office for your dental needs. Our goal is to provide you with high quality dental care. The Arkansas Department of Health (ADOH) has recommended that dental facilities and healthcare providers may resume services that require minimal protective equipment on May 11, 2020. Because dental work often creates aerosols, it carries an added risk of spreading COVID-19. This form is being provided to you to identify potential risks of dental treatment during COVID-19. If you or a member of your household are experiencing symptoms of COVID-19 (e.g., fever, cough, shortness of breath), please alert a member of our staff immediately.

While all dental care has certain inherent risks and complications, patients face additional risks during the COVID-19 pandemic. These include, but are not limited to, increased risk of exposure to COVID-19. While we are taking all reasonable precautions to prevent the spread of COVID- 19, it is impossible to eliminate that risk. Dentists and/or staff are exposed to multiple patients, who could be asymptomatic carriers of COVJD-19. Complications of COVID-19 may include acute respiratory distress syndrome, irregular heart rate, cardiovascular shock, severe muscle pain, fatigue, heart damage or heart attack. The risk of complications is increased for individuals aged 65 and older, and individuals with compromised immune systems and/or chronic disease.

By signing this form, you acknowledge that in-person treatment for your dental condition presents increased risk of contracting COVID-19. You further acknowledge that for us to perform the treatment, we must be closer than the CDC recommended 6 ft. in proximity. You further agree that you will follow certain procedures as required by the ADOH, including but not limited to hand washing and wearing a surgical mask at certain times. If you experience any COVID-19 symptoms after receiving dental treatment, please contact your primary health care provider AND our dental office immediately.

I give consent for myself/my child to receive dental treatment during the COVID-19 pandemic deemed necessary or recommended by the providers at this office.

This consent shall be considered in effect until rescinded or revoked.

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 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 inferences 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, and 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 wi II charge you $0 for each page, $0 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.

*You May Refuse to Sign This Acknowledgment*