Parent #1

Parent #2

For Boy

For Girl

Signatures

I understand that the information that I have provided is correct to the best of my knowledge, that 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.

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office. I understand that where appropriate, credit bureau reports may be obtained. 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

I,

Want to communicate via e-mail with Minnesota Orthodontics on matters related to my financial/insurance information and my dental treatment. I understand that any Confidential Health Information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, or any of its workforce members, liable for loss of any confidentiality associated with information transmitted via e-mail. Standard message and data rates may apply to text messages. 

I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via e-mail. Because this information is not encrypted I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions.

- By declining any email communication. You will not receive appointment reminders via email.

- There will be no communication with your general dentist via email (which most dentists prefer)

- You will not be able to send or receive requests to our office through our secure website. 

HIPAA E-Mail Release Form 

Before sending any non-encrypted e-mail communications (including attachments) containing Protected Health Information to any recipient, ensure that this Form has been signed and is on file Provide a copy to the Patient. Form 12 

I,

authorize Minnesota Orthodontics to submit a dental claim to the Minnesota Health Care Program dental insurance in order for them to evaluate the medial necessity of treatment for this patient . Your child will meet with one of our licensed dental assistants to take photos and x-rays, plus a scan of their teeth. The Doctor will not be present at this appointment. They will review these records after the appointment and determine a diagnosis and treatment plan for their orthodontic needs; they do not determine the medical necessity of the case. We supply this required information to your insurance company and their examining committee will make the determination of whether or not the case is medically necessary based on the stat mandated criteria for orthodontic treatment to be covered. 

 Our office participates with ONLY 2 MHCP plans: Civic Smiles/Delta Dental. I understand that I will be responsible for any bill incurred due to a change in my insurance plan or a lapse in coverage. 

 In order for our office to participate with your Minnesota Health Care Program insurance we have set aside the hours of 9:00am to 2:30pm daily for appointments. Please understand that some school and work time will have to be missed with any orthodontic treatment. After two missed appointments we reserve the right to discontinue any further treatment. 

In order to reduce insurance fraud; we require you to present your insurance card at this appointment. If you do not bring the insurance card along we will need to reschedule the appointment. 

 Our office has a late policy; if you are more than 10 minutes late we will have to reschedule the appointment. We need the entire 30 minutes to complete the appointment. 

 The entire processes will take an average to 8-12 weeks. You will receive a letter from the insurance company stating if they have approved or denied the case, we receive our letter 1-2 weeks after you do. If the case has been approved we will contact you to schedule the appropriate appointment. If the case is denied our office will send you a letter with information on proceeding with treatment by self paying. 

AUDIO/PHOTO/VIDEO MEDIA RELEASE FORM

I grant permission to Minnesota Orthodontics and its agents or employees to use photographs and/or video and audio taken of me. These images may be used in advertisements, brochures, newsletters, posters in both printed and/or online media. I understand that my images may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my images or recordings.

I hereby agree to release, defend, and hold harmless Minnesota Orthodontics and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.

Before signing below, you have read this and fully understand the contents, meaning, and impact of this release. As the signer you understand that you are free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and have agreed that your failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

If under age 18, there must be a consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of the below and do hereby give my consent without reservation to the foregoing on behalf of this person.