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Parent/Guardian Information: How did you learn about our office? __________________________

1. Name: ________________________________________________________________ Preferred Name: _________________________

Relation to Patient: _____________________________ If Guardian or Step-Parent: Can you provide appropriate paperwork? YES / NO

Address (IF DIFFERS FROM PATIENT): ___________________________________________ ________________________ ________ ____________

SSN: ________-________-________ Date of Birth: ____/____/____ Email: __________________________________________________

Home Phone: (______) ______ - ______ Cell Phone: (______) ______ - ______ Work Phone: (______) ______ - ______ Ext: ______

2. Name: ________________________________________________________________ Preferred Name: _________________________ FIRST M.I. LAST

Relation to Patient: _____________________________ If Guardian or Step-Parent: Can you provide appropriate paperwork? YES / NO

Address (IF DIFFERS FROM PATIENT): ___________________________________________ ________________________ ________ ____________

SSN: ________-________-________ Date of Birth: ____/____/____ Email: __________________________________________________

Home Phone: (______) ______ - ______ Cell Phone: (______) ______ - ______ Work Phone: (______) ______ - ______ Ext: ______

Dental Insurance Information:

Primary Dental Insurance Secondary Dental Insurance

Insurance Co. Name: ____________________________________ Insurance Co. Name: _____________________________________

Subscriber’s Name: _____________________________________ Subscriber’s Name: ______________________________________

Employer’s Name: ______________________________________ Employer’s Name: _______________________________________

Group Name: __________________________________________ Group Name: ___________________________________________

Group #: _____________________________________________ Group #: _______________________________________________

Insured ID #: __________________________________________ Insured ID #: ___________________________________________

Ins. Co. Address: _______________________________________ Ins. Co. Address: _________________________________________

_____________________________________________________ ______________________________________________________

Ins. Co. Phone #: ___(______) ______ - ______ Ins. Co. Phone #: ___(______) ______ - ______

Patient Information: Today’s Date: ____/____/____

Name: __________________________________________ Nickname: ______________ Date of Birth: ____/____/____ Gender: M / F

Patient primarily lives with: □ Both parents □ Mother(s) □ Father(s) □ Grandparent(s) □ Other: ____________________________

Address: ___________________________________________________ ________________________________ ________ ____________

Home Phone: (______) ______ - ______ Cell Phone: (______) ______ - ______ Work Phone: (______) ______ - ______ Ext: ______

NEW PATIENT INFORMATION

As a courtesy, we accept assignment of benefits from your insurance carrier. As we deal with insurance on your behalf, carriers require that we keep your signature on file. Please sign the statements below such that we may offer this service.

I have reviewed the treatment plan(s) and I authorize the release of any information relating to the claim(s). I hereby authorize direct payment to the above named dentists of the group insurance benefits otherwise payable to me.

_________________________________________________ Signature of insured parent / guardian

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF HEALTH PLAN DOCUMENTSIn considering the amount of healthcare expenses to be incurred, I, the undersigned, have insurance and / or employee dental care benefits coverage with the above captioned, and hereby assign and convey directly to Coastal Pediatric Dental & Anesthesia all dental care benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctors and practice. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctors to release all information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health and dental benefits claim submissions. I hereby convey to the above named doctors and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health and dental care plan with respect to medical expenses incurred as a result of the services I received from the above named doctors and practice and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctors and practice in any attempts by such doctors and practice to pursue such claim, chose in action or right against my insurers and/or employee health and dental care plan, including, if necessary, bring suit with such doctors and practice against such insurers and/or employee health and dental care plan in my name but at such doctors and practice’s expenses. This assignment will remain in effect for seven years or until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. I have read your authorization and legal assignment of benefits and agree to its terms. My signature authorizes you to disclose my PHI in the manner described above and acknowledges that I will receive a copy of this completed form for my own records.

By signing below you acknowledge and accept legal assignment of benefits.

____________________________ ______________________ __________ Signature of insured parent / guardian Relationship to patient Date

For those patients without insurance coverage, payment in full is required at the time of the treatment. For patients with insurance, the co-pay and/or deductible is due at the time of treatment. The parent who accompanies the child to our office is responsible for payment at the time of service unless arrangements have been made prior to the visit. All office correspondence will be addressed to the child’s place of residence. It is important that you keep our office aware of changes in your address, phone numbers, and insurance status. By signing below you acknowledge that you understand our office policies.

____________________________ ______________________ __________ Signature of parent / guardian Relationship to patient Date

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3.

Pediatric Health History

I. Please Mark Appropriate Answer: (Leave Blank If You Do Not Understand The Question)

9. ☐ YES ☐ NO10. ☐ YES ☐ NO11. ☐ YES ☐ NO12. ☐ YES ☐ NO13. ☐ YES ☐ NO14. ☐ YES ☐ NO15. ☐ YES ☐ NO16. ☐ YES ☐ NO17. ☐ YES ☐ NO18. ☐ YES ☐ NO19. ☐ YES ☐ NO

Asthma or trouble breathing?Earaches or ear problems?Hearing problems?Eye problems?Speech problems?Sinus problems?Cleft lip / cleft palate?Apnea / snoring?Heart murmur or other heart problems?Rheumatic fever or rheumatic heart disease?Skin problems? (e.g. eczema, hives, impetigo)

20. ☐ YES ☐ NO21. ☐ YES ☐ NO22. ☐ YES ☐ NO23. ☐ YES ☐ NO24. ☐ YES ☐ NO25. ☐ YES ☐ NO26. ☐ YES ☐ NO27. ☐ YES ☐ NO28. ☐ YES ☐ NO29. ☐ YES ☐ NO30. ☐ YES ☐ NO

High Blood Pressure?Cystic Fibrosis?Ulcers or stomach problems?Eating disorder / unusual diet?Hepatitis, jaundice, liver disease?Weight loss?Prolonged diarrhea?Bladder or kidney problems?Arthritis or joint problems?TMJ or jaw joint problems?Scoliosis or spine problems?

31. ☐ YES ☐ NO32. ☐ YES ☐ NO33. ☐ YES ☐ NO34. ☐ YES ☐ NO35. ☐ YES ☐ NO36. ☐ YES ☐ NO37. ☐ YES ☐ NO

Fainting or dizziness?Autism?Developmental delays or growth delays?Learning Disorders?Attention deficit / hyperactivity disorder (ADHD)

Mental problems or behavior disorders?

Brain or head injury?

39. ☐ YES ☐ NO40. ☐ YES ☐ NO41. ☐ YES ☐ NO42. ☐ YES ☐ NO43. ☐ YES ☐ NO44. ☐ YES ☐ NO

Psychiatric treatment?Diabetes / high blood sugar?Thyroid problems?Anemia?Blood disorder or transfusion?

Excessive bleeding / hemophilia?

Sickle cell disease /trait?

38. ☐ YES ☐ NO

Is your child’s general health good?1. ☐ YES ☐ NO

Birth Date: / / Gender: M / FPatient Name:Today’s Date: / /

Phone:Parent/Guardian Name:

Pediatrician’s Name: Pediatrician’s Phone:

Was your child born prematurely? If YES, how many weeks?2. ☐ YES ☐ NO

Has your child been hospitalized or had surgery?If YES, explain:

3. ☐ YES ☐ NO

Date of last medical exam:Is your child being treated by a physician now?If YES, for what?

4. ☐ YES ☐ NO

Does your child take any medicine / medications? (e.g. presciption/over the counter/herbal)If YES, what?

5. ☐ YES ☐ NO

Does your child have any allergies to drugs, food, other (e.g. latex)?If YES, what and explain type/severity of reaction?

6 . ☐ YES ☐ NO

Date of last dental exam:Has your child had problems with prior dental treatment?If YES, please explain:

7. ☐ YES ☐ NO

Is your child in pain now or having a problem with their teeth?If YES, please explain:

8. ☐ YES ☐ NO

II. Does Your Child Have or Has Your Child Had:

III. Does Your Child Have or Has Your Child Had:

Instructions: Please CHECK EACH BOX. DO NOT DRAW ANY LINES. Please answer honestly and to the best of your ability. If you have any questions or concerns, please leave the question unanswered until the nurse or thedoctor can address your questions or concerns.

Pediatric Health History CON’T

4.

58. ☐ YES ☐ NO Strep Throat?

53. ☐ YES ☐ NO Measles / Rubella? 59. ☐ YES ☐ NO Tuberculosis (TB)?54. ☐ YES ☐ NO Mumps? 60. ☐ YES ☐ NO Whooping Cough / Pertussis?55. ☐ YES ☐ NO Chicken Pox / Varicella? 61. ☐ YES ☐ NO Cytomegalovirus (CMV)?56. ☐ YES ☐ NO Scarlet Fever? 62. ☐ YES ☐ NO HIV / AIDS?57. ☐ YES ☐ NO Mononucleosis? 63. ☐ YES ☐ NO Problem with general anesthesia?

V. Does Your Child Have or Has Your Child Had:

64. ☐ YES ☐ NO Smoke tobacco? 66. ☐ YES ☐ NO Use recreational drugs?65. ☐ YES ☐ NO Chew tobacco or snuff? 67. ☐ YES ☐ NO Use alcohol?

VI. Does Your Child Have or Has Your Child:

VII. Females (Teens) Only:68. ☐ YES ☐ NO Is your child taking birth control pills? 69. ☐ YES ☐ NO Could your child be pregnant?

VIII. All Patients:

73. ☐ YES ☐ NO Is your child up to date on all their vaccinations?

To the best of my knowledge, I have answered every question completely and accurately. I will inform Coastal Pediatric Dental & Anesthesia of any change in my child’s health and / or medications.

Parent or Guardian’s signature: Date:

Relationship to the patient: Patient’s name:

Recall Review: VA Law requires an updated medical history with every sedation or anesthesia appointment and at least annually. A new form must be completed with any changes in health or medications.

Practitioner’s signature: Date:

70. ☐ YES ☐ NO Does your child have / had any other diseases, medical problems or syndromes not listed here?If YES, please explain:

71. ☐ YES ☐ NO Does your child play organized sports?If YES, please explain:

72. ☐ YES ☐ NO Does your child wear a helmet or mouthguard when playing recreational or organized sports?If YES, please explain:

Parent or Guardian’s signature: Date:

Parent or Guardian’s signature: Date:

IX: Emergency Contact: (OTHER THAN THE PERSON WHO WILL NORMALLY ATTEND THE CHILD’S APPOINTMENTS)Name:Relationship to the patient:

Phone:

***DO NOT SIGN BELOW UNTIL YOUR NEXT VISIT***

45. ☐ YES ☐ NO46. ☐ YES ☐ NO47. ☐ YES ☐ NO48. ☐ YES ☐ NO49. ☐ YES ☐ NO

Cerebral Palsy?Epilepsy, convulsions or seizures?Headaches or migraines?Hydrocephaly or shunts?Radiation Treatment? Please list to what parts of the body and when:

50. ☐ YES ☐ NO51. ☐ YES ☐ NO52. ☐ YES ☐ NO

Cancer or tumor?Immune disorder?Chemotherapy?

IV. Does Your Child Have or Has Your Child Had:

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COASTAL PEDIATRIC DENTAL & ANESTHESIA

OFFICE POLICIES

Appointment Policy When you schedule an appointment for your child at Coastal Pediatric Dental & Anesthesia, that time period is reserved specifically for them. Changes to the appointment affect our dentists, team, and other patients, so we ask that you call at least 48 hours in advance if you need to cancel an appointment. Here are some other points about dental appointments that we ask you to remember:

• Please arrive 10-15 minutes in advance so your child can receive dental care on time and you can complete any additional paperwork.

• Please accept our apology in advance if your appointment is delayed when we accommodate an injured child for dental emergency care. We would do the same if your child were in need of emergency treatment.

Please note that surgical and anesthesia appointments require our doctors’ individual attention until all necessary care is provided. We will devote the same undivided attention to your child.

• If you arrive 15 minutes late for an appointment, you will be asked to reschedule at the next available time.

• If two missed or broken appointments occur consecutively without notice of cancellation, then our office reserves the right to not reschedule the appointment. We also reserve the right to not reschedule general anesthesia appointments for repeat noncompliance or cancelling without notice.

• Broken appointments are subject to a $50.00 fee.

• Coastal understands the value of school and education. Unfortunately, it is not possible for Coastal to treat all children at hours that do not interfere with school or work. However, we are happy to provide a work or school excuse with a doctor’s signature so that the absence will be excused.

Financial Policy Coastal Pediatric Dental & Anesthesia thanks you for choosing our office for your child’s dental care. We are committed to their oral health and wellness. We ask that you understand that the payment of dental fees is considered part of your child’s care.

• The adult who brings a child to Coastal is responsible for the payment of their dental care. We cannot send statements to other persons. Payment is expected at the time of service.

• We will put aside the part of the balance your insurance provider covers for 60 days. If insurance does not pay the balance within this time period, then you are responsible for any remaining balance or unpaid bills.

• Understand that most insurance companies only pay a portion of dental fees and we are legally required to have you pay your part at the time of treatment. In addition, insurance companies may not cover all medically and dentally necessary procedures.

• Coastal does not have a contract with your insurance company, only you do. Insurance companies do not guarantee payment until a claim is made. Therefore, estimates are merely estimates of what the insurance covers. This is true even with pre-authorizations.

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• Since insurance coverage is a contract between you, your employer, and the insurance company, we remind you that any unpaid balances on the account will be your responsibility. We will assist you if you have questions about insurance delays or amounts, though we have found that insurance providers are more responsive to patients (their beneficiaries).

• Our policy at Coastal is that all outstanding balances be paid within 30 days of a receipt of statement. If the fee is not completely paid, then it will gain a 1.5% monthly (18% annually) interest rate.

• If a patient does not have insurance, then we require full payment of fees at the time of treatment unless other arrangements have been made (e.g. with the CareCredit financing program).

• Payment may be made in the form of cash, credit card (Visa, MasterCard, American Express, Discover), check, or debit card.

• If we have not received payment or contact from you within 90 days after treatment, then we reserve the right to take further action with a collection agency.

Parent Participation Unlike many other pediatric dental offices, we welcome parents to our treatment area so they can sit with their child during cleaning appointments. Because of limited space, we ask that only one adult accompany the child back to the treatment area for operative (fillings and crowns) appointments. Parents can sit nearby as a silent observer so cooperation and trust can develop between your child and our doctors. This allows children to communicate directly with our dentist and team without distractions and safety concerns.

We find that there are times when a child’s dental experience can be enhanced when a parent is absent from the treatment area, especially as the child grows older. We may ask a parent to wait in our office lobby so their child can communicate more directly with our dentists and build a relationship of trust with them.

Coastal Pediatric Dental & Anesthesia does not allow parents to remain in the operating rooms during treatment under IV sedation and general anesthesia.

Cell phones are discouraged in our treatment area because conversations carried by others may distract your child, cutting into the line of communication with them and our dentists. If you need to use your cell phone, please feel free to step outside to take the phone call. Due to patient privacy concerns, please do not record photo/video in the treatment areas.

Our goal is to give your child a safe, positive dental experience at Coastal Pediatric Dental & Anesthesia. Please call our office should you have any questions or concerns.

Patient Name: _________________________________________________________________________________________________ Responsible Party Name: ____________________________________________________________________________________

(Please Print)

Responsible Party Signature: _______________________________________________________________________________ Date: ____________________________________________________________________________________________________________

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For Dental Examination, Cleaning, Radiographs, Fluoride Treatment, Patient Management Techniques,

Restorative Dentistry, and Acknowledgment of Receipt of Information

We recognize the exceptional privilege that we enjoy as specialists in pediatric (children’s) dentistry and anesthesia.

Coastal Pediatric Dental & Anesthesia is honored to be your partner in achieving your family’s oral health goals.

Your child's welfare and safety are of utmost importance to us. State Law requires health professionals to provide their

prospective patients with information regarding the treatment or procedures they are contemplating. Please read this form

carefully and ask about anything you do not understand. We will be pleased to explain it.

It is our intent that all professional care delivered in our dental office shall be of the best possible quality we can provide.

Providing high quality care can sometimes be made very difficult, or even impossible, because of the lack of cooperation

of some patients. All efforts will be made to obtain the cooperation of pediatric dental patients by the use of warmth,

friendliness, persuasion, humor, charm, gentleness, kindness and understanding.

There are several behavior management techniques that are occasionally used by pediatric dentists to gain and encourage

the cooperation of child patients and prevent patients from causing injury to themselves due to potentially harmful

movements. The more frequently used pediatric dentistry behavior management techniques are as follows:

1. Tell-show-do: The dentist or assistant explains to the child what is to be done in simple terms and then shows the child

what is to be done by demonstrating with instruments on a model or the child’s or dentist’s finger. Then the procedure

is performed in the child's mouth as described. Praise is used to reinforce cooperative behavior.

2. Positive reinforcement: We always use this technique, which rewards the child who displays any positive behavior.

Rewards include compliments, praise, a pat on the back, a hug or a prize.

3. Voice control: The attention of the child is gained by changing the tone or volume of the dentist’s voice (caring, warm,

but firm).

4. Stabilization: The assistant will always comfort our patient by holding their hands. The dentist or the assistant may

need to gently stabilize the child's head and/or control leg movement to prevent any sudden movement. On rare

occasions, it may be necessary to use passive restraints such as a papoose board.

In addition, Coastal Pediatric Dental & Anesthesia is fortunate to have the facilities and dedicated anesthesia support to

offer a full range of pharmacologic adjuncts to dental care. These services may be offered both in our practice and at

certain local hospitals and surgical centers. These options include:

5. Sedation: Sometimes drugs are used to relax a child who needs it. These drugs may be administered orally or via

inhalation (nitrous oxide). The child does not become unconscious, and should be responsive and may remember and

understand what is occurring. You will be further informed and your specific consent obtained if we feel there is a need

for sedation.

6. General Anesthesia: The dentist performs the dental treatment with the child anesthetized in either our or the

hospital’s operating rooms. An anesthesiologist will be present to deliver the anesthesia care. You will be further

informed and your specific consent will be sought if there is a need for general anesthesia.

If you believe that sedation or anesthesia will be necessary, please do not hesitate to let us know.

Pediatric Dentistry Consent

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I request and authorize Coastal Pediatric Dental & Anesthesia, the practice of Drs. Kari Cwiak and Jonathan Wong, and

other health care professionals on staff to perform or assist in the performance of the following but not necessarily limited

to:

• Examination and radiographs (X-rays) as determined by the dentist.

• Cleaning of the teeth and application of topical fluoride.

• Application of plastic “sealants” to the fissures or grooves of the teeth.

• Administration of local anesthetics.

• Treatment of diseased or injured teeth with dental restorations (fillings, crowns and pulpotomies).

• Removal (extractions) of one or more teeth.

• Treatment of diseased or injured oral tissues (hard and/or soft).

• Replacement of missing teeth with space maintainers and/or dental prosthesis.

• Postponing or delaying treatment at this time if unable to complete treatment with the aforementioned

behavior management techniques.

I understand that unforeseen conditions or circumstances may arise during the course of the above-described procedure or

treatment. Hence, I consent to and authorize the performance of any care, procedure, or treatment not specified above that

the dentist reasonably believes necessary or advisable as a result of these unforeseen events.

The purpose of the above is to maintain dental health and we anticipate that result. No guarantees or assurances can be

made as to the results that may be obtained.

Bleeding, swelling, discomfort, and bruising can occur after any dental procedure. However, not completing necessary

dental treatment can result in abscess, infection, pain, fever, swelling and substantial risk to the developing permanent

teeth.

I consent to the administration of local anesthetic that the dentist deems necessary, and/or nitrous oxide. I understand that

the risks involved with the administration of local anesthetics may also be characterized by excitation, depression,

nervousness, dizziness, blurred vision, tremors, drowsiness, convulsions (seizures), unconsciousness and possibly

cardiac/respiratory arrest. Allergic reactions may occur which may be characterized by skin eruptions, itching, and

swelling. I understand that the alternative of not using local anesthetic could cause a great deal of discomfort and pain.

The risk of this alternative could be emotional damage and psychological trauma.

I understand that should the child become uncooperative during dental procedures with movement of the head, arms

and/or legs, dental treatment cannot be safely provided. During such movements, it may be necessary to use behavioral

management techniques, including stabilization as described previously. My signature below signifies I authorize the use

of stabilization techniques, when deemed absolutely necessary to avoid possible injury to the child.

I understand that I may refuse to consent to any and all treatment. However, refusal of medically necessary treatment or

requests/refusals that would cause treatment to be below the standard of care or present a risk to you or the patient may

result in termination of the dentist-patient partnership.

I certify that I have read and understand the above. I accept the risk of substantial and serious harm, if any, in hope of

obtaining the desired beneficial results of this treatment or procedure. I acknowledge that the dentist has explained all of

the above to me in a thorough and comprehensible manner, and that my questions about my treatment and its attendant

risks have been answered to my satisfaction.

Patient’s Name: _______________________________________________________ Date of Birth: _____/_____/_____

Signature: ___________________________________________________ Relationship to Patient: ________________

Witness: _________________________________________________ Date: _____/_____/_____ Time: _____:_____

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NOTICE OF PRIVACY PRACTICES

PARENT/GUARDIAN DISCLOSURE FORM

This form is required by the Health Insurance Portability and Accountability Act of 1996 in compliance with the privacy regulation effective

for this office on September 1st, 2017, only if our office wishes to use or disclose your protected health information for any other purpose not

clearly spelled out in our office Privacy Policy Notice.

To use or disclose your protected health information in such cases, our office must receive prior written authorization from you. Our office

will condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization.

The purpose for which our office is requesting your authorization is to diagnose and complete treatment. The information to be disclosed

would include your protected health information (PHI). The information may be disclosed to, but not limited to, laboratories, hospitals,

insurance companies, medical and dental referrals, and other health care professionals. This form also authorizes the use of photography as a

diagnostic tool.

By agreeing to this authorization, you understand that the potential for information disclosed pursuant to this authorization may be subject to

re-disclosure by the recipient and no longer protected by the privacy regulation of HIPAA. You also understand that you are entitled to

receive a copy of this authorization form.

————————————————————————————————————————————————

I, __________________________________________, have received and reviewed this office’s Notice of Privacy Practices. Parent / Guardian Name

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of the protected health

information, (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be

made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

I wish to be contacted in the following manner: (CHECK ALL THAT APPLY)

□ Home Phone: (________)________-________ □ Work Phone: (________)________-________ □ Mobile Phone: (________)________-________

□ Message with Detailed Information

□ Leave Call-Back Number ONLY

□ Message with Detailed Information

□ Leave Call-Back Number ONLY

□ Message with detailed information

□ Receive Text Messages.

Written Communication:

□ Okay to Email to this Email: _________________________________________________________

□ Okay to send mail to this address: __________________________________________________

____________________________________________________________________________________________

□ Okay to Fax to this Number:

_____________________________________________

□ Other: ___________________________________

(Please note that Coastal cannot ensure end user security of your email, text messages, or e-faxes.)

Patient’s Name: ____________________________________________________________________________________________________________________________

Patient or Parent/Guardian’s Signature: _________________________________________________________________________ Date:____/____/____

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Authorization for Release/Use of Protected Health Information in the Form of Photos, Radiographs, and Electronic Images

Your photos and x-rays are part of your diagnostic and clinical record and are considered to be protected health information under federal HIPAA Privacy Laws. We make use of radiographs (x-rays), photographs, and digital images. These images may be used for diagnosis, documentation, reference, teaching, and research publication. Some cases that present exceptional results, and/or particularly remarkable smiles, and/or interesting situations may be utilized for demonstration, education or advertising to potential and existing patients in our office either in print media, social media, television, on digital media and/or on our webpage. In some instances, you may be recognizable in some of these images. By signing this form, you are authorizing us and releasing us from any liability resulting from the use/release of such images. Your authorization and release to use images will in no way affect the quality of your results in our office. If you do not wish Coastal Pediatric Dental & Anesthesia to use such images, please initial your preferred privacy options below. We always do our best to provide exceptional dentistry to all patients. INITIAL ALL THAT APPLY ______ I DO NOT authorize the use of my images where my/my child’s face is identifiable (i.e. social media).

______ I DO NOT authorize the use of my images where only my/my child’s teeth are identifiable (i.e. medical studies,

transferring to another doctor).

______ I DO NOT authorize the use of my radiographs (identifying information removed)(i.e. medical studies,

transferring to another doctor).

The purpose of this request to release and/or disclose the PHI described above is for personal reasons. I understand that I have the right to revoke this Authorization, in writing, at any time by notifying the office above. Such revocation will not affect actions taken by the requesting person prior to the date they received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by this rule. I understand that my health care provider cannot condition treatment on whether I sign this Authorization. This Authorization will expire at such time that: _____ I determine that I no longer wish for my/my child’s images to be used and I revoke this authorization in writing;

or

_____ The following date: _______________________________ (within one year of current date).

or

______ I AGREE to the use of my child’s images and radiographs for all social media and medical purposes for

an indeterminate time.

Patient Name: _____________________________________________________________________________________________________________________________

Patient or Parent/Guardian’s Signature: _________________________________________________________________________ Date:____/____/____

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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Patient Name: ___________________________________________________________________________________________________________________

First MI Last Maiden or Other Name Date of Birth: _________/__________/__________ Medical Record/SSN #: ____________________________________________________ Phone: (________) _______________ Service Date: _________/_________/__________

Address: ___________________________________________________City: ____________________________State: _______ Zip Code: __________

□ I authorize Drs. Kari Cwiak and Jonathan Wong to disclose the following records related to the date above: Records: □ All records □ Medical / Dental Records □ HIV/STD □ Diagnostic Records (lab, x-ray, etc.) □ Drug and alcohol related □ Treatment Records □ Billing/Claims Records

Please Release These Records To: (i.e. Step-parents, Grandparents, Spouse, additional medical doctors, etc.) 1. Name: _________________________________________________________________________Relationship:_________________________________ Address: ___________________________________________________City: ____________________________State: _______ Zip Code: __________

Phone: (________) _______________ Fax: (________) _______________ Email: ______________________________________________________

2. Name: _________________________________________________________________________Relationship:_________________________________ Address: ___________________________________________________City: ____________________________State: _______ Zip Code: __________

Phone: (________) _______________ Fax: (________) _______________ Email: ______________________________________________________ If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions, per your request, and no longer protected by these regulations.

You may revoke this authorization in writing at any time by sending written notification to:

Office: Coastal Pediatric Dental & Anesthesia Fax: 757-961-9988

6161 Kempsville Circle, STE 345 Norfolk, VA 23502

Please Note: Revocations Do Not Apply To Information That Has Already Been Disclosed Prior To Revocation Being Received.

You may decline to sign this authorization. Declining to sign will not affect your ability to obtain treatment or your eligibility for benefits unless this authorization is being performed solely to create information to be sent to another entity. You have the right to receive a copy of this authorization. This authorization expires one year from date of signing or on ________/________/____________.

____________________________________________________________________________________________________________________________________ Patient or Legal Representative Signature Date

____________________________________________________________________________________________________________________________________ Print Patient or Legal Representative Name Relationship

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Your Information. Your Rights. Our Responsibility.

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.

Notice of Privacy Practices

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.

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Get an electronic or paper copy of your dental record.

• You may ask to see or get an electronic or paper copy of your medical record and other health information that we have about you. Ask us how to do this.

• We will provide a copy or 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 / dental records

• You can ask us to correct health and dental 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 will tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, a home or office phone) or to send mail to a different address.

• You may give permission to receive protected health information electronically via email or text message.

• 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.

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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 will 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.

• 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.

Choose someone to act for you

File a complain if you feel your rights are violated

• You can file a complaint if you feel we have violated your rights by contacting us using the information on the last page of this notice.

• You may also 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 on 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 would want us to do, and we will follow your instructions.

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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• 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

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.

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• We can use your health information and share it with other professionals that are treating you.

• Example: A dentist treating you asks your primary care physician about your overall health condition.

• We can use and share your 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 (such as appointment reminders).

Treat You

Run our practice

Bill for your services • We can use and share your health information to bill and get payment from insurance plans or other entities.

• Example: We give information about you to your dental insurance plan so it will pay for your services.

Coastal Pediatric Dental & Anesthesia, the practice of Drs. Kari Cwiak and Jonathan Wong, does not maintain or manage a hospital directory, nor do we create or maintain psychotherapy notes at this practice.

Our Uses and Disclosures: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.

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• We can share health information about you for certain situations such as:• Preventing Disease• Helping with product recalls• Reporting adverse reactions to medications• Reported suspected abuse, neglect, or domestic

violence• Preventing or reducing a serious threat to

anyone’s health or safety

Help with public health and safety issues

Do research • We can use or share your information for health and/or dental 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 are complying with federal privacy law.

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

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

Our Responsibilities to You:• 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 website.

This Notice of Privacy Practices applies to the following organizations:

Kari Cwiak, DMD & Jonathan L Wong, DMD, PLLCD/B/A Coastal Pediatric Dental & AnesthesiaPrivacy Officer: Jonathan L Wong, DMD6161 Kempsville Circle, Ste 345Norfolk, VA 23502757-963-0001www.CoastalPediatricDental.com

Effective Date of Notice: 09/01/2017

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