Child Registration Forms

Child New Patient Registration

1 Patient Information

2 Medical Information

3 General Information

4 Insurance Information

5 Medical History

6 Dental History

7 Patient Health Information

8 Office Policy

9 Privacy Policy, Release & Waiver

Step 1 of 9

Patient

Patient's Name(Required)

First Last

Patient prefers to be called

School

Birth Date(Required)

Sex(Required)

Home Address

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Home Phone

Parent/Guardian

Custodial parent(s) name(s)(Required)

Relationship to Patient(Required)

Father's Full Name

Father's Address (if different from patient address)

Street Address City State ZIP Code

Father's Occupation

Father's Home Phone (if different)

Father's Cell Phone

Father's Work Phone

Mother's Full Name

Mother's Address (if different from patient address)

Street Address City State ZIP Code

Mother's Occupation

Mother's Home Phone (if different)

Mother's Cell Phone

Mother's Work Phone

Dentist

Patient's Dentist

Address

City State

Last Seen

Reason

Other dentists/dental specialists now being seen

Name

City, State

Reason

Physician

Patient's Physician

Address

City State

Last Seen

Reason

Other physicians/health care provides being seen now:

Name

City, State

Reason

Click the plus icon to add additional rows

General Information

What concerns you about your teeth?

Who suggested you might need orthodontic treatment?

Why did you select our office?

If you've had any previous orthodontic treatment, please describe.

If any other family members have been treated in this office, please name them.

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

Financial Responsibility

Who is financially responsible for this account?(Required)

Address (if different from patient address)

Street Address City State / Province / Region ZIP / Postal Code

Employer

Home Phone (if not listed previously)

Cell Phone (if not listed previously)

Email Address

Office Policy

Scheduling and Appointments

Our office hours are Monday 9-6, Tuesday through Thursday 8-5 and Friday 8-1 (administrative only). Appointments are usually scheduled at four (4) to eight (8) week intervals during treatment. The majority of these visits can be scheduled in the early morning or afternoon; however, appointments 1 hour or longer (putting braces on, taking braces off, impressions) need to be scheduled in the morning or early afternoon. We do understand that this may be inconvenient for some patients, but it does allow us to provide our best possible treatment and also to accommodate as many patients as possible during the afternoon hours.

It is the patient’s responsibility to make timely follow-up appointments. These can be scheduled after your visit, and are therefore, scheduled in advance. This will help to ensure that you can choose times/days that will work for you or give you ample notice to make arrangements. If you wait until the week before to attempt to schedule your followup visit you probably will not be able to get your most ideal time slot. Your appointment is reserved especially for you, and so we do require 24 hours notice to cancel. If you are 10 minutes late for your appointment please understand that we will likely need to reschedule your appointment in order to prevent inconvenience to the rest of our patients. Repeated missed appointments or last-minute cancellations may result in rescheduling fees.

As a courtesy to you we confirm your appointment 1-2 days prior, but please do not depend on this, since messages can be accidentally erased or overlooked.

Treatment Cooperation

We will always do our best to provide the absolute best orthodontic treatment for our patients, because we care. In return, we expect excellent treatment cooperation. This common goal for doctor and patient is what results in superior orthodontics. Below you will find a list of our expectations for all of our patients and/or parents:

• Cooperation in elastic wear
• Proper oral hygiene
• Maintaining regular dental cleanings and checkups with your general dentist (every 3 months)
• Keeping of regular adjustment appointments at recommended intervals
• Eliminating foods and eating habits that break or distort appliances
• Reporting lost or broken appliances promptly

At the least, poor compliance will extend treatment time, and at the most, it may even prevent us from completing your treatment at all. In these extreme cases we will be obligated to terminate active treatment.

Financial Policy

When treatment is initiated we will draw up a financial agreement (contract), so that the terms of payment are clear. We offer a 5% courtesy for payment in full, or we can finance over the anticipated length of treatment with monthly payments. Payments are accepted in the form of cash, personal check, and credit card (Visa, Mastercard, Discover, American Express). Please be aware that there is a $40 charge for returned checks, and multiple instances may result in our accepting cash-only payments.

A monthly payment is a convenient way to spread out the cost of orthodontic treatment and is not related to treatment progress or appointments; therefore, payment is still collected even if there is no appointment during the month. For your convenience we do offer an autopay program, so that you will never miss a payment and avoid annoying late fees. Below is further information about our payment plans:

• Accounts become due on the 1st of the month; however your autopay may be processed on the 1st, the 10th, the 15th or the 25th of the month.
• If no payment is received by the 28th of the month a $10 late fee is assessed, and a statement is sent to inform you of this balance (*statements are only sent to patients with a balance*).
• At 60 days delinquent additional late fees will be applied.
• The balance of the total treatment fee is due upon appliance removal, unless otherwise specified. If your autopay agreement is still in progress after braces are removed we will continue to process payments as agreed upon until the balance is paid. If we cannot successfully process your autopay we will contact you for updated payment information; however, if a payment is missed after appliances are removed your account may be sent to collections.
• We understand that life happens, and so the primary goal of our collections system is to find a payment arrangement that will work for you and your family, even when circumstances change. We do not wish to dismiss patients from our practice; however, if you do not respond to our multiple requests for payment or work with us to rearrange your contract, we are left with no other option.

If you transfer or move during the course of treatment your account will be prorated, and the account will be settled prior to sending your records to your new orthodontist.

Insurance

Once we verify and assign your orthodontic insurance benefit, an insurance ledger is established with the expected amount of insurance benefits. We will then be responsible to file your periodic insurance claims, accept payment and apply this to your account.

Please be aware that many insurances do not pay your benefit in a lump sum, rather they send payment over the course of treatment. If the patient’s benefit decreases, changes or terminates, the unpaid balance is transferred back into the patient’s ledger and will be the responsibility of the patient.

Assignment of Benefit Authorization

I hereby authorize insurance payment directly to Franklin Orthodontics, PLLC, otherwise payable to me. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize this orthodontic office to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature(Required)

Date

We love to celebrate the exciting moments of orthodontic treatment with our patients! This may include social media posts and photographs at special times, such as braces on or finishing treatment. If you would like to provide consent for these activities please sign below.

Signature

Date

I have read the above document and understand the policies of Franklin Orthodontics, PLLC.

Signature(Required)

Date

Privacy Policy and Release & Waiver

Your Information. Your Rights. Our Responsibilities.
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 Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care 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 health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for 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, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly

Choose someone to act for you

• 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.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on this form.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close
friends, or others involved in your care • Share information in a disaster relief situation
• Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you

• We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

• We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

• We can use or share your information for health research.

Comply with the law

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• 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 must follow the duties and privacy practices described in this notice and give you a copy of it.
• 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.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective date: 7/21/2020

Release of information(Required)

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Please read carefully(Required)

I have read the above questions and understand them. I will not hold my orthondotist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Untitled

Child Registration Forms

Child New Patient Registration

Patient

Home Address

Parent/Guardian

Dentist

Physician

General Information

Financial Responsibility

Dental Insurance

Medical History

Has your child had allergies or reactions to any of the following?

Dental History

Now or in the past has your child had:

Patient Health Information

Family Medical History

Office Policy

Scheduling and Appointments

Treatment Cooperation

Financial Policy

Insurance

Assignment of Benefit Authorization

Privacy Policy and Release & Waiver

Your Rights

Your Choices

Our Uses and Disclosures

Your Rights

Get an electronic or paper copy of your medical record

Ask us to correct your medical record

Request confidential communications

Ask us to limit what we use or share

Get a list of those with whom we’ve shared information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you feel your rights are violated

Your Choices

In these cases, you have both the right and choice to tell us to:

In these cases we never share your information unless you give us written permission:

In the case of fundraising:

Our Uses and Disclosures

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Respond to lawsuits and legal actions

Our Responsibilities

Changes to the Terms of this Notice