Child HHF | WH Orthodontics (wh) – Forms

Patient Form - Child
In an effort to provide the best service possible, we ask you to fill out this form as completely as possible! Thanks for your cooperation!
Patient's Name * Required
First Middle Initial Last
Nickname
Birthdate * Required
Gender * Required
- Male
- Female
Home Address * Required
Street Address City State Zip Code
Email
Phone
School
Grade
List any sports or musical instruments
Siblings
Please list any other family members seen in our office
Who may we thank for referring you to our office?
How did you hear about our practice? * Required
- Ad
- Family / Friend
- Internet
- Dentist
Parent/Guardian Information
Parent/Guardian Name * Required
First Middle Initial Last
Relationship to Patient * Required
- Mother
- Father
- Step-Mother
- Step-Father
- Guardian
Marital Status * Required
- Single
- Married
- Divorced
Gender * Required
- Male
- Female
Address
(If same as child's, you can say "Same as Child's")

Street Address City State Zip Code
Birthdate * Required
Email * Required
Cell Phone * Required
Home Phone
Work Phone
Preferred method of communication * Required
- Home Phone
- Cell Phone
- Text / SMS
- Email
Employer * Required
Occupation * Required
Is there an additional parent or guardian that needs to be added? * Required
- Yes
- No

Emergency Contact Information
Name * Required
First Middle Initial Last
Primary Phone * Required
Email
Hidden
Person(s) OK to release appointment or medically related information to concerning child

Dental Insurance
Do you have dental insurance? * Required
- Yes
- No

Dental Insurance Information
Policy Owner Name * Required
Policy Owner Birthdate * Required
Relationship to Patient * Required
- Mother
- Father
- Step-Mother
- Step-Father
- Guardian
Policy Owner's Address
(If same as child's, you can say "Same as Child's")

Street Address City State Zip Code
Policy Owner Phone * Required
Policy Owner Employer * Required
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required
Do you have secondary dental insurance? * Required
- Yes
- No

Secondary Dental Insurance Information
If you have additional dental insurance you would like us to be aware of, please include that here. Otherwise, you can skip this section, and continue with your application.
Policy Owner Name * Required
Policy Owner Birthdate * Required
Relationship to Patient * Required
- Mother
- Father
- Step-Mother
- Step-Father
- Guardian
Policy Owner's Address
(If same as child's, you can say "Same as Child's")

Street Address City State Zip Code
Policy Owner Phone * Required
Policy Owner Employer * Required
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required

Notice of Privacy Policy
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your protected health information (i.e., Individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleaning, surgery, etc.);
- To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment etc.);
- To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who may have a role in your treatment;
- To other patients and third parties who may see or over here incidental disclosures about your treatment, scheduling, etc,;
- To your family and close friends involved in your treatment; and / or,
- We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have a right to:
- Request restrictions on the use and disclosure of your protected health information;
- Request confidential communication of your protected health information;
- Inspect and obtain copies of your protected health information through asking us;
- Amend or modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected health information; and,
- You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our privacy contact person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
- To abide by the terms of our Privacy Notice that is currently in effect;
- To advise you of our right to change the terms of this Privacy Notice and to make new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
- Honor any requests by you to restrict the use or disclosure of your protected health information;
- Amend your protected health information if, for example, it is accurate and complete; or,
- Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature if you have any questions about the information in this Notice please ask for our privacy contact person or direct your questions to the person at our office address. Thank you.

Health Insurance Portability and Accountability Act
Through the 1996 Health Insurance Portability and Accountability Act, the Department of Health and Human Services established national standards for among other things, the privacy of protected health information. In compliance with these federal regulations, Wilson & Hendrickson Orthodontics may not discuss your medical care with anyone without your express written permission, except in the case of an emergency or as required by law. This does not apply to disclosing information to carry out treatment, payment, or health care operations.

List below the first and last names and relationship to the patient of people with whom you give Wilson & Hendrickson Orthodontics permission to discuss your case (i.e. medication refills, test results, appointment scheduling, billing information, medical history, etc.)

Parents and guardians, be sure to list yourself as well as any other family members or guardians you grant permission.
Name * Required
First Middle Last
Relationship * Required
Name
First Middle Last
Relationship * Required
Name
First Middle Last
Relationship * Required
Name
First Middle Last
Relationship * Required
Name
First Middle Last
Relationship * Required
Name
First Middle Last
Relationship * Required

Office Guidelines
We require at least 24 hours notice to cancel an appointment. Any missed appointment will result in a $20.00 fee, which will need to be paid prior to any future appointments.

By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward. Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.
Consent * Required
I confirm that I have read, understand and agree to the office guidelines.
We require at least 24 hours notice to cancel an appointment. Any missed appointment will result in a $20.00 fee, which will need to be paid prior to any future appointments.

By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward.
Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.

Notice of Photo Release
I hereby acknowledge that I have been advised that photographs and images will be taken of me or my child, beforehand, during, and after procedures. The photographs will be taken by one of the members of our office. I hereby acknowledge that photographs may be taken during my, or my child's, time in our office. I hereby give my consent for this office to use the photographs under the following circumstances: Internet Advertising, on our website, on our social media outlets, or in any print advertising.

I grant this office and it’s employees, legal representatives, and associates the irrevocable and unrestricted right to use and publish photographs or video footage of me, or imagery in which I may be included, for editorial, trade, advertising, and web use. I also grant this office the right to alter any images or photographs without restriction and without my inspection or approval. I hereby release this office and their legal representatives from all claims and liability relating to said imagery.
Consent * Required
I confirm that I have read, understand and agree to the notice of photo release.
I hereby acknowledge that I have been advised that photographs and images will be taken of me or my child, beforehand, during, and after procedures. The photographs will be taken by one of the members of our office. I hereby acknowledge that photographs may be taken during my, or my child's, time in our office. I hereby give my consent for this office to use the photographs under the following circumstances: Internet Advertising, on our website, on our social media outlets, or in any print advertising.

I grant this office and it’s employees, legal representatives, and associates the irrevocable and unrestricted right to use and publish photographs or video footage of me, or imagery in which I may be included, for editorial, trade, advertising, and web use. I also grant this office the right to alter any images or photographs without restriction and without my inspection or approval. I hereby release this office and their legal representatives from all claims and liability relating to said imagery.

Signature
By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $30.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward. Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.
Signature of Parent/Guardian * Required
Comments
This field is for validation purposes and should be left unchanged.

Step 1 of 12 - Patient Information

Patient Form - Child

Parent/Guardian Information

Additional Parent/Guardian Information

Emergency Contact Information

Dental Insurance

Dental Insurance Information

Secondary Dental Insurance Information

Patient Medical and Dental History

Patient Medical History

Notice of Privacy Policy

Health Insurance Portability and Accountability Act

Office Guidelines

Notice of Photo Release

Signature