New Patient Form - Rittenhouse Smiles

Primary Insurance Company

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I certify that I have read and I understand the questions above.

I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor)

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Reviewed by:

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Today's Date

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FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

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This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me:

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NOTICE OF PRIVACY PRACTICES

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

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We are required to abide by the terms of this Notice of Privacy Practices. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time, as well as for any information we receive in the future. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

<h2 style="text-align: center;">NOTICE OF PRIVACY PRACTICES</h2> 
<h3 style="text-align: center;">NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION</h3> 
<h3 style="text-align: center;">PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US</h3> 
 
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We are required to abide by the terms of this Notice of Privacy Practices. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time, as well as for any information we receive in the future. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

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, or to family and friends you approve.

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 and Limitations: 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. You also have the right to request restrictions on disclosure of PHI
(Personal Health Information), or alternative means of communication (e.g, home or business phone) to ensure privacy. We are not required to agree to all requests, and we may say “no” if it is not reasonable or would affect your care. If you pay for a service or item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your insurer. We will say “yes” unless a law requires us to share that information.

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

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

Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect.

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

<h3>USES AND DISCLOSURES OF HEALTH INFORMATION</h3> 
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, or to family and friends you approve. 
 
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 and Limitations: 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. You also have the right to request restrictions on disclosure of PHI 
(Personal Health Information), or alternative means of communication (e.g, home or business phone) to ensure privacy. We are not required to agree to all requests, and we may say “no” if it is not reasonable or would affect your care. If you pay for a service or item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your insurer. We will say “yes” unless a law requires us to share that information. 
 
Marketing Health-Related Services: We will not use your health information for marketing communications or sell your health information without your written authorization. 
 
Required by Law: We may use or disclose your health information when we are required to do so by law or national security activities. 
 
Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect. 
 
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 electronic or paper copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you.

Amendment: You have the right to request that we amend your health information. We may say “no” to your request, but we’ll tell you why in writing.

Accounting: You can request a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable fee if you ask for another one within 12 months.

Representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

<h3>PATIENT RIGHTS</h3> 
Access: You have the right to look at or get electronic or paper copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you. 
 
Amendment: You have the right to request that we amend your health information. We may say “no” to your request, but we’ll tell you why in writing. 
 
Accounting: You can request a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable fee if you ask for another one within 12 months. 
 
Representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

CANCELLATION POLICY

We do value your time, so we do not overbook appointments and increase wait times. For this reason, we require 24 hour notice for all cancellations. There will be a cancellation fee of $75 associated with all appointments broken without at least 24 hours of advance notice. Thank you for your trust in our practice”. But you can word it however you want to incorporate with the form. We just want them to know we need 24 hour notice.

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 our EthicsPoint Help Line which is (888) 366-6034. 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 with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer.

<h3>QUESTIONS AND COMPLAINTS</h3> 
 
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 our EthicsPoint Help Line which is (888) 366-6034. 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 with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer.

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

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From the Blog

Rittenhouse Smiles

2 weeks ago

⭐️Fun Dental Facts for those relaxed Sunday readers🦷⭐️

🦷Americans buy more than 14 million gallons of toothpaste every year.

🦷Coconuts are a natural anti-bacterial food and can help reduce the risk of developing gum disease and cavities.

🦷Halloween is the biggest candy-selling holiday, followed by Christmas, Easter, and Valentine's Day.

🦷25% of adults DO NOT brush twice a day. This increases their risk of developing tooth decay by 33%.

🦷Roughly 75% of school children worldwide have active dental cavities.

🦷48% of young adults have untagged themselves from a photo on Facebook because of their smile.

🦷90% of a bad breath smell originates in the mouth.

🦷People who smoke are 2-7 times more likely to develop periodontal disease than non-smokers.

🦷It was customary during the middle ages to kiss a donkey if you had a toothache.

🦷Tooth enamel is the hardest structure in the human body.

🦷Roughly 25% of American adults have no teeth.

🦷The average human being produces 100,000 gallons of saliva during their lifetime.

🦷Tooth decay is the second most common disease, second only to the common cold.

🦷People prefer blue toothbrushes to red ones.

🦷Teeth start to form in utero before we are born.

🦷Almost 65 million American adults have some form of periodontal disease. Of this number 38.4% are women, 56.4% are men.

🦷Expectant mothers with poor oral hygiene are 7X more likely to deliver premature and low birth weight babies.

🦷95% of American adults with diabetes also have periodontal disease.

🦷People with periodontal disease are 2X more likely to develop heart disease.

🦷People who drink 3 or more cans of soda daily have 62% more tooth decay, fillings, and tooth loss than people that don't drink soda.

🦷The first toothbrush with bristles was made in China in 1498. Bristles from hogs, horses, and badgers were used.

🦷Replacing a toothbrush after illnesses helps prevent the potential for re-infection.

🦷It takes 43 muscles to frown. It only takes 17 to smile.

🦷61% of adults are attracted to somebody by their smile alone.

🦷An apple a day may keep the doctor away, but it also makes you 3X more likely to develop dental decay.

🦷By drinking one can of soda daily, the average American gains 15 lbs each year.

🦷The human tongue is as unique as a fingerprint. No two people have the same tongue print.

🦷There are more bacteria in the human mouth than there are people on the Earth.

🦷The average woman smiles 62 time a day. The average man? Only 8 times.

🦷Kids laugh roughly 400 times a day. The average adult laughs only 15 times per day.

🦷In North America, over 3 million miles of dental floss are purchased annually.

🦷A fossilized T-Rex tooth can weigh up to a pound.

🦷In 200 A.D., the Romans used a mixture of bones, eggshells, oyster shells, and honey to clean their teeth.

🦷A snail's mouth is no larger than the head of a pin, yet it can contain over 25,000 teeth.

🦷A single can of soda contains 10-12 teaspoons of sugar. The recommended daily dietary intake of sugar is 4 teaspoons.

🦷According to a survey by Time magazine, 59% of people would rather have a dental appointment than sit next to someone who is talking on a cell phone.

🦷In the 1800s, blacksmiths and barbers also served as dentists.

🦷Toothpicks are the object most often choked on by Americans.

🦷The stone-faced farmer in artist Grant Wood's famous "American Gothic" painting was actually the artist's dentist.

🦷Sports-related injuries account for approximately 5 million missing teeth per year.

🦷Americans spend $100 billion a year on hair care products, and only $2 billion a year on dental care products.

🦷Contrary to popular belief, George Washington's famous dentures were not made from wood. His four pairs of custom choppers were crafted from gold, ivory, lead, and a mixture of human, donkey, and hippopotamus teeth.

🦷The cotton candy making machine that made widely consumed cotton candy possible was co-invented by a dentist. Before it was cotton candy, the fluffy confection was called "fairy floss."

🦷The earliest known dentist was Hesi-ren, an egyptian "doctor of the tooth" who lived around 3000 B.C.
The saying "cat got your tongue" originated 2500 years ago in ancient Assyria where conquered soldiers and criminals had their tongues cut out and fed to the king's cats.

🦷Cavities in teeth have been filled since the earliest of times with a variety of different materials, including gum, stone chips, and even turpentine resin.

🦷The lifespan of a taste bud is about 10 days. The five known tastes detected by taste buds are: bitter, sour, salty, sweet, and umami. Umami was identified in 1908 by a Japanese research and the chemical responsible for it is monosodium glutamate.

🦷60% of people don't known that a sore jaw, when combined with chest pain, can signal a heart attack - especially in women.

🦷Every year, kids in North America spend close to half a billion dollars on chewing gum.

The average toothbrush contains about 2500 bristles grouped into about 40 tufts per toothbrush. The tufts are folded over a metal staple and forced into pre-cored holes in the head and fused into the head with heat. The handle is made of at least two materials, usually plastic and rubber.

🦷The grips used for the handle are: precision, power, spoon, oblique, and distal oblique.

🦷90% of system diseases have oral manifestations.

🦷Sugar Facts: Chemical manufacturers use sugar to grow penicillin. A teaspoon of sugar after a hot curry with extinguish the furnace in your mouth. A spoonful of sugar added to a vase will prolong the life of freshly cut flowers.

🦷In the 1800s, people who had false teeth in England ate in their bedrooms before gatherings and events at the dinner table. This unique Victorian tradition protected them against the embarrassment of having their teeth 'fall off' while dining.

🦷Dolphins use their teeth to grab only, not to chew, as dolphins' jaws have no muscles.

🦷Mosquitoes have 47 teeth.

🦷In 1905, dental assistant Irene Newman was trained to clean teeth. She became the first dental hygienist. ... See MoreSee Less