Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

General Patient Information( * mandatory to fill )

How do we contact you?( * mandatory to fill )

I have received a copy of the Dental Materials Fact Sheet as required by law


SIGNATURE
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(Your IP Address : )

Parent/Guardian Information

Please select below

Do You Have Primary Dental Insurance?
Yes No
Do You Have Secondary Dental Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

SIGNATURE

I understand the information that I have given above is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status, contact information, and insurance information. I authorize the dental staff of FUNtastic Dental and Orthodontics to perform the necessary dental services my child may need. I permit payment of insurance benefits directly to the dentist for services rendered. I recognize and accept responsibility for payment of services not covered by insurance benefits. I understand that I am responsible for payment of services rendered andalso responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.


 
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Secondary Insurance Information( * mandatory to fill )

SIGNATURE

I understand the information that I have given above is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status, contact information, and insurance information. I authorize the dental staff of FUNtastic Dental and Orthodontics to perform the necessary dental services my child may need. I permit payment of insurance benefits directly to the dentist for services rendered. I recognize and accept responsibility for payment of services not covered by insurance benefits. I understand that I am responsible for payment of services rendered andalso responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.


 
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(Your IP Address : )
SIGNATURE
 
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(Your IP Address : )

Medical History

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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physicians care now?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Have you ever been hospitalized or had a major operation?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmur
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Valve prolapse
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
I have answered all the above questions

Comments *
Pediatrican Name *
Phone
Address

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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE
 
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(Your IP Address : )

Office Policies

Please take the time to read our office policies and ask us for any clarification if needed.

1. Our Office Policy on FUN One of our office policies is to have FUN. We foster creating a pleasant and comfortable environment for team members as well as patients and their families. Our office also routinely participates in fun days at the office like our Halloween & Christmas parties and other celebrations. This office also promotes children's extracurricular activities. All through the year, we sponsor local sports teams. Several times a year our dentists and staff visit local schools to educate students on dental care and good dental habits. Lastly. we often participate in continuing education courses to keep us up-to-date on the best technology for your kids.

2. Our Office Policy on Scheduling Appointments Children tend to do better in the dental office when they are not tired. Therefore, we encourage morning appointments, especially for pre-school or nervous children. For many children, just a simple filling at the end of a long day, when they are tired, can seem like a major ordeal. Please keep in mind, one of our goals is to make dentistry as pleasant as possible for your child. Also keep in mind that a dental appointment is an excused absence from school, and we can provide you with a school excuse/work excuse letter.

3. Our Office Policy on Cancelling and/or Failing Appointments When we schedule an appointment for your child, that time is reserved solely for your child. We do not double book and we take pride in the fact that because we value your time, as much as we hope you value ours, we make every effort to see your child at the time scheduled. For this reason, it is very important that you have your child in the office at the time scheduled. If you are more than 15 minutes late, it may be necessary to reschedule your child's visit. We ask that a minimum 24-hour notice be given for cancellations. We need this amount of time so that we can contact a child from our waiting list to offer the appointment.

4. Our Office Policy on Financial Provisions and Payment We are committed to providing your child with the best possible care. In order to achieve this goal, we need your assistance and your understanding of our payment policy. The parent or guardian noted as the responsible party on the initial new patient form is financially responsible. Payment and co-payments for dental services are due the day that dental services are rendered. We accept cash, checks, money orders, MasterCard, Visa, Discover, and American Express. Returned checks are subject to a $25 fee. Note: Regarding parents or guardians who are divorced. separated. or single: we are not in a position to mediate payment arrangements between parents or guardians.

5. Our Office Policy on Dental Insurance We are committed to providing your child with the best possible dental care regardless of insurance benefits. In order to achieve this goal, we need your assistance and your understanding of YOUR child's insurance benefits. The parent or guardian noted as the respon¬sible party on the initial new patient form is financially responsible for the account, regardless of who the policy holder for the insurance is. If the child has secondary insurance, we will be happy to file a dental claim, provided we are given all applicable information that we are able to verify. However, we are not in a position to mediate payment arrangements between parents or guardians.
As a courtesy to you, we will file a dental claim with your child's insurance. YOU MUST REALIZE, HOWEVER, THAT:
  • Your insurance is a contract between you, your employer and the insurance company.
  • We are not responsible for how your insurance company processes claims or what benefits they pay for. Which is why we can ONLY provide you with an ESTIMATE of YOUR insurance coverage.
  • Insurance companies set their own fee schedules and percentages paid are based on their fees not OUR office fees.
  • Not all dental services are a covered benefit.
  • lnsurance claims not paid by insurance company within 60 days become the sole responsibility of the responsible party. By law, insurance companies must pay claims within 30 days. Most do, but some do not. We have given those companies up to 60 days to pay. After 60 days, if there is no payment from the insurance company, the responsible party is responsible to pay that claim and given another 30 days to make a payment in full. If you have not paid your balance by this 90 day mark, and have not made financial arrangements with us, the responsible party's account will be sent to a collections agency and you will be responsible for all service fees.
  • We are only "in-network" with Delta Dental Premier insurance plan. However, we accept assignment of benefits from ALL PPO insurance plans because PPO plans offer "out-of-network" benefits which allow you to choose the very best healthcare providers for your child.
    • I have read the above office policies in their entirety. By signing below, I acknowledge that I am aware of and understand FUNtastic Dental & Orthodontics' office policies as stated above.
SIGNATURE
 
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(Your IP Address : )

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 HEALTHINFORMATION 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 fdllow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect March 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 creat-ed 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, accredita¬tion, 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 cani-iot practica¬bly 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   . for each page, $    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 informa¬tion 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 alterna¬tive 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 officer: Zulma
Telephone: 562-627-8800 Fax: 562-627-9292
E-mail: info@funtasticdental.com Address: 2700 Bellflower Blvd. #217 Long Beach. CA 90815

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I  ,have received a copy of this office's Noice of Privacy Practices.
(Please click below to draw/upload sign)
SIGNATURE
 
(Your IP Address : )
Thank you for visiting Funtastic Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

General Patient Information

Child's First Name:     Child's Last Name:     Child's Preferred Name:     Sex:     Age:     Dob:    

Child's First Name:     Child's Last Name:     Child's Preferred Name:     Sex:     Age:     Dob:    

Child's First Name:     Child's Last Name:     Child's Preferred Name:     Sex:     Age:     Dob:    

Address

Home Address:     City:     State:     Zip:    
Home Phone:     Cell Phone:     Email Address:    
Name of adult accompanying child today:     Relationship:     Previous Dentist Name/phone number:     Date of last dental visit:     How did you hear about our office (Relative/Friend's Name, Website, Facebook, etc):     Reason for today's visit(Consultation, Dental Exam, Dental Clearing, Dental x-rays,etc):    

I have received a copy of the Dental Materials Fact Sheet as required by law

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Parent/Guardian Information

Parent/Guardian's Name:     Relationship:     Mailing Address:     City:     State:     Zip Code:     Home Number:     Cell number:     Date Of Birth:     Age:     Marital Status:     Social Security Number:     Driver's License:    

Parent/Guardian's Name:     Relationship:     Mailing Address:     City:     State:     Zip Code:     Home Number:     Cell number:     Date Of Birth:     Age:     Marital Status:     Social Security Number:     Driver's License:    

Primary Insurance Information

Primary Policy Holder's Full Name:     Employer's Name:     Insurance Company:     Subscriber ID#:     Group#:     DOB:     Social Security #:    
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Secondary Policy Holder's Full Name:     Employer's Name:     Insurance Company:     Subscriber ID#:     Group#:     DOB:     Social Security #:    

I understand the information that I have given above is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status, contact information, and insurance information. I authorize the dental staff of FUNtastic Dental and Orthodontics to perform the necessary dental services my child may need. I permit payment of insurance benefits directly to the dentist for services rendered. I recognize and accept responsibility for payment of services not covered by insurance benefits. I understand that I am responsible for payment of services rendered andalso responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Do You have Secondary Insurance? Yes No
Medical History
Are you under a physicians care now?
Yes
No
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes
No
If yes, please explain:
Are you taking any medication, pills or drugs?
Yes
No
If yes, please explain:
Details:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please explain:
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Taking oral contraceptives Nursing
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Local anesthetics
Others
Details:
Do you or Have you experienced the following ?
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotherapy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmur Heart Trouble / Desease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure Hives or Rash Hypoglycemia
Irregular Heartbeat Kidney Problem Leukemia
Liver Disease Low Blood Pressure Lung diseases
Mitral Valve prolapse Pain in Jaw Joints Parathyroid Disease
Psychiatric Care Radiation Treatments Recent Weight Loss
Renal Dialysis Rheumatic Fever Rheumatism
Scarlet Fever Shingles Sickle Cell Disease
Sinus Trouble Spina Bifida Stomach/Intestinal Disease
Stroke Swelling of Limbs Thyroid Disease
Tonsillitis Tuberculosis Tumors or Growths
Ulcers Venereal Disease Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
If yes, please explain:
Comments:     Pediatrican Name:     Phone:     Address:    

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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Office Policies

Please take the time to read our office policies and ask us for any clarification if needed.
1. Our Office Policy on FUN One of our office policies is to have FUN. We foster creating a pleasant and comfortable environment for team members as well as patients and their families. Our office also routinely participates in fun days at the office like our Halloween & Christmas parties and other celebrations. This office also promotes children's extracurricular activities. All through the year, we sponsor local sports teams. Several times a year our dentists and staff visit local schools to educate students on dental care and good dental habits. Lastly. we often participate in continuing education courses to keep us up-to-date on the best technology for your kids.

2. Our Office Policy on Scheduling Appointments Children tend to do better in the dental office when they are not tired. Therefore, we encourage morning appointments, especially for pre-school or nervous children. For many children, just a simple filling at the end of a long day, when they are tired, can seem like a major ordeal. Please keep in mind, one of our goals is to make dentistry as pleasant as possible for your child. Also keep in mind that a dental appointment is an excused absence from school, and we can provide you with a school excuse/work excuse letter.

3. Our Office Policy on Cancelling and/or Failing Appointments When we schedule an appointment for your child, that time is reserved solely for your child. We do not double book and we take pride in the fact that because we value your time, as much as we hope you value ours, we make every effort to see your child at the time scheduled. For this reason, it is very important that you have your child in the office at the time scheduled. If you are more than 15 minutes late, it may be necessary to reschedule your child's visit. We ask that a minimum 24-hour notice be given for cancellations. We need this amount of time so that we can contact a child from our waiting list to offer the appointment.

4. Our Office Policy on Financial Provisions and Payment We are committed to providing your child with the best possible care. In order to achieve this goal, we need your assistance and your understanding of our payment policy. The parent or guardian noted as the responsible party on the initial new patient form is financially responsible. Payment and co-payments for dental services are due the day that dental services are rendered. We accept cash, checks, money orders, MasterCard, Visa, Discover, and American Express. Returned checks are subject to a $25 fee. Note: Regarding parents or guardians who are divorced. separated. or single: we are not in a position to mediate payment arrangements between parents or guardians.

5. Our Office Policy on Dental Insurance We are committed to providing your child with the best possible dental care regardless of insurance benefits. In order to achieve this goal, we need your assistance and your understanding of YOUR child's insurance benefits. The parent or guardian noted as the respon¬sible party on the initial new patient form is financially responsible for the account, regardless of who the policy holder for the insurance is. If the child has secondary insurance, we will be happy to file a dental claim, provided we are given all applicable information that we are able to verify. However, we are not in a position to mediate payment arrangements between parents or guardians.
As a courtesy to you, we will file a dental claim with your child's insurance. YOU MUST REALIZE, HOWEVER, THAT:
  • Your insurance is a contract between you, your employer and the insurance company.
  • We are not responsible for how your insurance company processes claims or what benefits they pay for. Which is why we can ONLY provide you with an ESTIMATE of YOUR insurance coverage.
  • Insurance companies set their own fee schedules and percentages paid are based on their fees not OUR office fees.
  • Not all dental services are a covered benefit.
  • lnsurance claims not paid by insurance company within 60 days become the sole responsibility of the responsible party. By law, insurance companies must pay claims within 30 days. Most do, but some do not. We have given those companies up to 60 days to pay. After 60 days, if there is no payment from the insurance company, the responsible party is responsible to pay that claim and given another 30 days to make a payment in full. If you have not paid your balance by this 90 day mark, and have not made financial arrangements with us, the responsible party's account will be sent to a collections agency and you will be responsible for all service fees.
  • We are only "in-network" with Delta Dental Premier insurance plan. However, we accept assignment of benefits from ALL PPO insurance plans because PPO plans offer "out-of-network" benefits which allow you to choose the very best healthcare providers for your child.
    • I have read the above office policies in their entirety. By signing below, I acknowledge that I am aware of and understand FUNtastic Dental & Orthodontics' office policies as stated above.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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 HEALTHINFORMATION 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 fdllow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect March 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 creat-ed 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, accredita¬tion, 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 cani-iot practica¬bly 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   . for each page, $    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 informa¬tion 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 alterna¬tive 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 officer: Zulma
Telephone: 562-627-8800 Fax: 562-627-9292
E-mail: info@funtasticdental.com Address: 2700 Bellflower Blvd. #217 Long Beach. CA 90815

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I  ,have received a copy of this office's Noice of Privacy Practices.

 
  
 
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