GIVE KIDS A SMILE. Sincerely,
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- Tyrone Paul Benson
- 5 years ago
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2 GIVE KIDS A SMILE MOBILE DENTAL PROGRAM Dear Parent or Guardian: Bethany s Give Kids a Smile program provides free dental care for children who cannot afford to get dental care on their own. Our dental bus will come to your child's school. All service individuals are licensed dental professionals. Your child may qualify for this program if he or she: has never been to the dentist has not been to the dentist in the last six months receives Medicaid / the medical card is not covered under a private dental insurance Examples include Humana, Delta Dental, MetLife, etc. The bus visits schools all over the Quad Cities. On the day that the bus comes to your child's school, your child will receive oral health education a dental exam teeth cleaning fluoride treatment sealants, if necessary There is NO CHARGE for services on the Give Kids a Smile dental bus (If your child is enrolled in the state Medicaid system, Medicaid will be billed for services provided on the bus and for any follow-up services that are necessary.) If you want to have your child participate in this program, please complete the enclosed forms and return it to your school. Sincerely, Evena Wash Supervisor, Give Kids a Smile Have questions? Call me at (309) ! Follow Bethany for Children & Families on Facebook to see when the Give Kids a Smile bus will be at your child s school!
3 GIVE KIDS A SMILE PERMISSION FORM PLEASE PRINT IN INK M F Child s First Name Child s Last Name Date of Birth Gender Home Address City State Zip Code Parent/Guardian First Name Last Name Phone Address Emergency Contact Name Relationship to Child Emergency Contact Phone Child s School Child s Teacher Child s Grade Child s Medicaid Recipient ID Number or Hawk-i Number What race do you consider your child? Black White Hispanic / Latino Asian American Indian / Native Alaskan Hawaiian Native Pacific Islander Multi-Racial What type of DENTAL INSURANCE does your child have? Humana Delta Dental MetLife Medicaid (Medical Card, Title 19) Meridian Illini Care / Envolve Hawk-i None Where does your child go for regular dental care? Name of Dentist/Office Date of Last Visit Has your child been seen on the Give Kids a Smile dental bus before? Yes No For Office Use Only
4 GIVE KIDS A SMILE PERMISSION FORM PLEASE CHECK IF YES My child needs an antibiotic before a dental procedure. ADHD / ADD Heart Ailment / Angina Anemia Heart Attack Artificial Heart Valve Heart Murmur / Heart Defect Artificial Joints Hepatitis / Liver Problems Autism High / Low Blood Pressure Bleeding Disorder High Cholesterol Blood Disorder HIV / AIDS Brain Injury Kidney Disease Cancer Leukemia Caffeine Use Allergies Latex Nut Food Anesthetics Metals Medication List with Dosage Cerebral Palsy Chronic Earaches Chronic Headaches Chronic Pain Diabetes Downs Syndrome Epilepsy Fainting / Dizziness Fever Blisters / Cold Sores Hearing Difficulties Mental / Physical Disabilities Osteoporosis Pace Maker Pregnancy Radiation Treatment Rheumatoid Arthritis Seizure Disorder Stomach Disorder Thyroid Problems Tuberculosis Surgeries List with Date Asthma List triggers below. Carries Inhaler Gum Disease / Bleeding Gums Sensitive / Painful Teeth Jaw Pain (TMJ / TMD) Has Speech Impairments Has Difficulty Chewing Food Gags Easily Bites Nails Breathes through Mouth Grinds Teeth Sucks Thumb / Lips / Inner Cheek Brushes Twice a Day Flosses Daily Soda / Pop How Often? Sticky Foods How Often? Sugary Foods How Often? Tobacco What Type & How Often? For Office Use Only Sealants Placed: Health History Reviewed By: Dentist s Initials: Date:
5 GIVE KIDS A SMILE WAIVER FORM PLEASE READ THE WAIVER BELOW AND INITIAL IN INK IF YOU AGREE TO THE BELOW. I give permission for my child to be treated on the Give Kids a Smile dental bus from Bethany for Children & Families. I give permission for Bethany for Children & Families to transport my child from his or her school to the dental bus if the bus is parked off-site. I give permission for my child to be treated in a dental office or clinic if follow-up work is needed. I give permission for Bethany for Children & Families to transport my child to a follow-up dental appointment if I am not able to take my child to the appointment or do not have transportation. Transportation will be arranged on a case-by-case basis. If my child needs a specialist Pedodontist (for general pediatric dentistry), Endodontist (for root canals), Oral Surgeon (for tooth extractions), Periodontist (for gum disease), or Orthodontist (for braces) I agree to go with my child to this appointment. I give permission for audits to be performed and professional providers to return to my child s school to recheck his or her sealants and reseal if needed. Signature of Parent / Guardian / Legal Custodian Date ACKNOWLEDGEMENT OF RECEIPT OF GIVE KIDS A SMILE NOTICE OF PRIVACY PRACTICES I, as the parent or guardian, have received a copy of the Give Kids a Smile Notice of Privacy Practices. Signature of Parent / Guardian / Legal Custodian Date Permission and acknowledgment is valid for one year from the date of signature. For Office Use Only We attempted to obtain written acknowledgment of receipt of the Notice of Privacy Practices, but acknowledgment was not obtained because... Individual refused to sign Communication barriers prohibited obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment
6 GIVE KIDS A SMILE 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 Dentists participating in the Give Kids a Smile program may be required by applicable federal and state law to main the privacy of your health information. Protection of patient privacy is important to participants in the Give Kids a Smile program. This notice summarizes the privacy practices that will be followed by participants in the Give Kids a Smile program, and your rights concerning your health information. This Notice will apply to health information collected in connection with the Give Kids a Smile program and will remain in effect until replaced. You may request a copy of the Notice of Privacy Practices at any time. For more information about the privacy practices, or for additional copies of this Notice, please contact Bethany for Children & Families at (309) USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment. For example, we may use or disclose your health information to another dentist, physician, or other health care provider providing treatment to you. Your Authorization: Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. 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. 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 involved in your treatment to the extent necessary to help with your health care. Persons Involved in Care: 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 institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances. PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. Contact us at (309) for assistance in reaching the dentist or facility holding your health information. Disclosure Accounting: You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last six years, but not before April 14, Restriction: You may 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 may request that we communicate with you about your health information by alternative means or to alternative locations. We may agree to reasonable requests. Amendment: You may 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. QUESTIONS & COMPLAINS If you want more information about our privacy practices or have questions or concerns, please contact us at (309) If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your health information, or to have us communicate with you by alternative means or at alternative locations, you may contact us at (309) You may also 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.
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
Last: First: MI: Nickname:
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Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
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PATIENT REGISTRATION
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Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
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PATIENT REGISTRATION
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Facebook. Jamboree Dentistry Website. Insurance. Mailer. Internet Search. Community Impact Newspaper Ad. Walk In. Online Appointment Request
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