Dental Forms
Try our New DIGITAL FORMS!
Our Digital Forms allow you to fill out and securely submit your forms right from your own device!
PRINTABLE
Patient Registration Forms
Print and fill out your Dentistry Forms!
| New Patient Registration Forms Pack |
In addition to the Patient Registration Package above, you may also download the Request for Patient records form below,
so we may request your Dental Records and X-Rays from your previous provider's office.
so we may request your Dental Records and X-Rays from your previous provider's office.
| Records Release from Prior Dentist - Incoming Form.pdf |
| PA Private Dentist Report School |
| LD Financial Policies 140101.pdf |
| Notice of Privacy Practices.pdf |
| Records Release TO OTHER Dentist_Leaving Form |
Overview of updated Privacy Notice (09/23/2013)
- In effect on March 26th, a new HIPAA Final Rule was passed. Referred to as the Omnibus Rule.
- New regulations include required changes to the wording of our Notice of Privacy Practices with a compliance date of September 23rd, 2013.
- One change to the Notice involves fundraising and marketing. The Notice must now indicate if the patient's Protected Health Information (PHI) is used for fundraising and give the patient the right to opt out. (send in writing to our Privacy Manager)
- The new Notice must now inform the patient of the dental office's obligation to notify patients in the event of a breach of unsecured PHI.
- Further, the Notice must state that in the event a patient pays in full for a service out of pocket, the patient now has a right to request the dental office not to disclose treatment information for this service to a health plan.
- Lastly is a change to the patient's right to a copy of their health records. If applicable, a patient now has a right to an electronic copy of their records if they prefer.
- Distribution is only required to patients as they come in for appointments and only new patients who have not yet signed an Acknowledgement of Receipt Privacy Practices Notice with our office.
