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FREE IN-SCHOOLDENTAL SCREENING
The Mount Vernon School District, in partnership with Smile New York Outreach, is offering every child a FREE DENTAL SCREENING. At the dental screening, a licensed dentist will check your child’s mouth and teeth. A report will be provided for your child to take home.
For your ease and convenience, the in-school dentist will be back at a later date to see children needing preventive dental care including a cleaning, x-rays and sealants as necessary, or, they should be taken to their current dentist.
Be sure to have your child’s mouth and teeth checked in school for FREE. Simply complete and return the permission slip below.
YES, I would like my child to have a FREE DENTAL SCREENING at school.I have received the Notice of Privacy Practices on the back of this form.
Child’s Name_______________________________Birth Date___________Male/Female
School_________________________________________________________________
Teacher_______________________________________________Grade____________
Parent/Guardian Name____________________________________________________
Parent/Guardian Signature______________________________________Date_______
NOTI
CE O
F PR
IVAC
Y PR
ACTI
CES
THIS
NO
TICE
DES
CRIB
ES H
OW
MED
ICAL
INFO
RMAT
ION
ABO
UT Y
OU
MAY
BE
USED
AND
DIS
CLO
SED
AND
HOW
YO
U CA
N G
ET A
CCES
S TO
THI
S IN
FORM
ATIO
N.
THE
PRIV
ACY
OF
YOUR
MED
ICAL
INFO
RMAT
ION
IS IM
PORT
ANT
TO U
S. P
LEAS
E RE
VIEW
IT C
AREF
ULLY
. KEE
P FO
R YO
UR R
ECO
RDS
OUR
LEG
AL D
UTY
We
are
requ
ired
by a
pplic
able
fede
ral a
nd s
tate
law
to m
aint
ain
the
priva
cy o
f you
r hea
lth in
form
atio
n. W
e ar
e al
so re
quire
d to
give
you
this
Notic
e ab
out o
ur p
rivac
y pr
actic
es, o
ur le
gal d
utie
s, a
nd y
our r
ight
s co
ncer
n-in
g yo
ur h
ealth
info
rmat
ion.
We
mus
t fol
low
the
priva
cy p
ract
ices
that
are
des
crib
ed in
this
Notic
e wh
ile it
is in
ef
fect
. Th
is No
tice
take
s ef
fect
04/
14/0
3, a
nd w
ill re
mai
n in
effe
ct u
ntil w
e re
plac
e it.
We
rese
rve
the
right
to c
hang
e ou
r priv
acy
prac
tices
and
the
term
s of
this
Notic
e at
any
tim
e, p
rovid
ed s
uch
chan
ges
are
perm
itted
by a
pplic
able
law.
We
rese
rve
the
right
to m
ake
the
chan
ges
in o
ur p
rivac
y pr
actic
es a
nd
the
new
term
s of
our
Not
ice e
ffect
ive fo
r all h
ealth
info
rmat
ion
that
we
mai
ntai
n, in
cludi
ng h
ealth
info
rmat
ion
we c
reat
ed o
r rec
eive
d be
fore
we
mad
e th
e ch
ange
s. B
efor
e we
mak
e a
signi
fican
t cha
nge
in o
ur p
rivac
y pr
actic
es, w
e wi
ll cha
nge
this
Notic
e an
d m
ake
the
new
Notic
e av
aila
ble
upon
requ
est.
You
may
requ
est a
cop
y of
our
Not
ice a
t any
tim
e. F
or m
ore
info
rmat
ion
abou
t our
priv
acy
prac
tices
, or f
or
addi
tiona
l cop
ies
of th
is No
tice,
ple
ase
cont
act u
s us
ing
the
info
rmat
ion
liste
d at
the
end
of th
is No
tice.
USES
AND
DIS
CLO
SURE
S O
F HE
ALTH
INFO
RMAT
ION
We
use
and
disc
lose
hea
lth in
form
atio
n ab
out y
ou fo
r tre
atm
ent,
paym
ent,
and
heal
thca
re o
pera
tions
. Fo
r exa
mpl
e:Tr
eatm
ent:
We
may
use
or d
isclo
se y
our h
ealth
info
rmat
ion
to a
phy
sicia
n, s
choo
l nur
se o
r oth
er h
ealth
care
pr
ovid
er p
rovid
ing
treat
men
t to
you.
Paym
ent:
We
may
use
and
disc
lose
you
r hea
lth in
form
atio
n to
obt
ain
paym
ent f
or s
ervic
es w
e pr
ovid
e to
yo
u.
Heal
thca
re O
pera
tions
: W
e m
ay u
se a
nd d
isclo
se y
our h
ealth
info
rmat
ion
in c
onne
ctio
n wi
th y
our h
ealth
-ca
re o
pera
tions
. He
alth
care
ope
ratio
ns in
clude
qua
lity a
sses
smen
t and
impr
ovem
ent a
ctivi
ties,
revie
wing
the
com
pete
nce
or q
ualifi
catio
ns o
f hea
lthca
re p
rofe
ssio
nals,
eva
luat
ing
prac
titio
ner a
nd p
rovid
er p
erfo
rman
ce,
cond
uctin
g tra
inin
g pr
ogra
ms,
acc
redi
tatio
n, c
ertif
icatio
n, lic
ensin
g or
cre
dent
ialin
g ac
tivitie
s.
Your
Aut
horiz
atio
n: I
n ad
ditio
n to
our
use
of y
our h
ealth
info
rmat
ion
for t
reat
men
t, pa
ymen
t or h
ealth
care
op
erat
ions
, you
may
give
us
writt
en a
utho
rizat
ion
to u
se y
our h
ealth
info
rmat
ion
or to
disc
lose
it to
any
one
for
any
purp
ose.
If y
ou g
ive u
s an
aut
horiz
atio
n, y
ou m
ay re
voke
it in
writ
ing
at a
ny ti
me.
You
r rev
ocat
ion
will n
ot
affe
ct a
ny u
se o
r disc
losu
res
perm
itted
by y
our a
utho
rizat
ion
while
it wa
s in
effe
ct.
Unle
ss y
ou g
ive u
s a
writte
n au
thor
izatio
n, w
e ca
nnot
use
or d
isclo
se y
our h
ealth
info
rmat
ion
for a
ny re
ason
exc
ept t
hose
des
crib
ed in
this
Notic
e.
To Y
our F
amily
and
Frie
nds:
We
mus
t disc
lose
you
r hea
lth in
form
atio
n to
you
, as
desc
ribed
in th
e Pa
tient
Ri
ghts
sec
tion
of th
is No
tice.
We
may
disc
lose
you
r hea
lth in
form
atio
n to
a fa
mily
mem
ber,
frien
d or
oth
er
pers
on to
the
exte
nt n
eces
sary
to h
elp
with
you
r hea
lthca
re o
r with
pay
men
t for
you
r hea
lthca
re, b
ut o
nly
if yo
u ag
ree
that
we
may
do
so.
Pers
ons
Invo
lved
In C
are:
We
may
use
or d
isclo
se h
ealth
info
rmat
ion
to n
otify
, or a
ssist
in th
e no
tifica
-tio
n of
(inc
ludi
ng id
entif
ying
or lo
catin
g) a
fam
ily m
embe
r, yo
ur p
erso
nal r
epre
sent
ative
or a
noth
er p
erso
n re
spon
sible
for y
our c
are,
of y
our l
ocat
ion,
you
r gen
eral
con
ditio
n, o
r dea
th.
If yo
u ar
e pr
esen
t, th
en p
rior t
o us
e or
disc
losu
re o
f you
r hea
lth in
form
atio
n, w
e wi
ll pro
vide
you
with
an
oppo
rtuni
ty to
obj
ect t
o su
ch u
ses
or
disc
losu
res.
In
the
even
t of y
our i
ncap
acity
or e
mer
genc
y cir
cum
stan
ces,
we
will d
isclo
se h
ealth
info
rmat
ion
base
d on
a d
eter
min
atio
n us
ing
our p
rofe
ssio
nal ju
dgm
ent d
isclo
sing
only
heal
th in
form
atio
n th
at is
dire
ctly
rele
vant
to th
e pe
rson
’s in
volve
men
t in
your
hea
lthca
re.
We
will a
lso u
se o
ur p
rofe
ssio
nal ju
dgm
ent a
nd o
ur
expe
rienc
e wi
th c
omm
on p
ract
ice to
mak
e re
ason
able
infe
renc
es o
f you
r bes
t int
eres
t in
allo
wing
a p
erso
n to
pi
ck u
p fill
ed p
resc
riptio
ns, m
edica
l sup
plie
s, x
-rays
, or o
ther
sim
ilar f
orm
s of
hea
lth in
form
atio
n.
Mar
ketin
g He
alth
-Rel
ated
Ser
vice
s: W
e wi
ll not
use
you
r hea
lth in
form
atio
n fo
r mar
ketin
g co
mm
unica
tions
wi
thou
t you
r writ
ten
auth
oriza
tion.
Requ
ired
by L
aw:
We
may
use
or d
isclo
se y
our h
ealth
info
rmat
ion
when
we
are
requ
ired
to d
o so
by
law.
Abus
e or
Neg
lect
: W
e m
ay d
isclos
e yo
ur h
ealth
info
rmat
ion to
app
ropr
iate
auth
oritie
s if w
e re
ason
ably
belie
ve th
at yo
u ar
e a
pos-
sible
victim
of a
buse
, neg
lect,
or d
omes
tic vi
olenc
e or
the
poss
ible
victim
of o
ther
crim
es.
We
may
disc
lose
your
hea
lth in
form
ation
to
the
exte
nt n
eces
sary
to a
vert
a se
rious
thre
at to
your
hea
lth o
r saf
ety o
f the
hea
lth o
r saf
ety o
f oth
ers.
Natio
nal S
ecur
ity:
We
may
disc
lose
to m
ilitar
y aut
horit
ies th
e he
alth
infor
mat
ion o
f Arm
ed F
orce
s per
sonn
el un
der c
erta
in cir
-cu
msta
nces
. W
e m
ay d
isclos
e to
aut
horiz
ed fe
dera
l offic
ials h
ealth
info
rmat
ion re
quire
d fo
r law
ful in
tellig
ence
, cou
nter
intell
igenc
e,
and
othe
r nat
ional
secu
rity a
ctivit
ies.
We
may
disc
lose
to co
rrecti
onal
institu
tion
or la
w en
forc
emen
t offic
ial h
aving
lawf
ul cu
stody
of
prot
ecte
d he
alth
infor
mat
ion o
f inm
ate
or p
atien
t und
er ce
rtain
circu
msta
nces
.
Appo
intm
ent R
emin
ders
: W
e m
ay u
se o
r disc
lose
your
hea
lth in
form
ation
to p
rovid
e yo
u wi
th a
ppoin
tmen
t rem
inder
s (su
ch a
s vo
icem
ail m
essa
ges,
postc
ards
, or l
ette
rs).
PATI
ENT
RIG
HTS
Acce
ss:
You
have
the
right
to lo
ok a
t or g
et co
pies o
f you
r hea
lth in
form
ation
, with
limite
d ex
cept
ions.
You
may
requ
est t
hat w
e pr
ovide
pho
toco
pies.
We
will u
se th
e fo
rmat
you
requ
est u
nless
we
cann
ot p
racti
cably
do
so.
You
mus
t mak
e a
requ
est in
writ
ing
to o
btain
acc
ess t
o yo
ur h
ealth
info
rmat
ion.
You
may
requ
est a
cces
s by s
endin
g us
a le
tter t
o th
e ad
dres
s at t
he e
nd o
f this
Not
ice.
Disc
losu
re A
ccou
ntin
g: Y
ou h
ave
the
right
to re
ceive
a lis
t of in
stanc
es in
whic
h we
or o
ur b
usine
ss a
ssoc
iates
disc
losed
your
he
alth
infor
mat
ion fo
r pur
pose
s, ot
her t
han
treat
men
t, pa
ymen
t, he
althc
are
oper
ation
s and
certa
in ot
her a
ctivit
ies, f
or th
e las
t 6
year
s, bu
t not
bef
ore
April
14, 2
003.
If y
ou re
ques
t this
acc
ount
ing m
ore
than
onc
e in
a 12
-mon
th p
eriod
, we
may
char
ge yo
u a
reas
onab
le, co
st-ba
sed
fee
for r
espo
nding
to th
ese
addit
ional
requ
ests.
Rest
rictio
n: Y
ou h
ave
the
right
to re
ques
t tha
t we
place
add
itiona
l res
tricti
ons o
n ou
r use
or d
isclos
ure
of yo
ur h
ealth
info
rmat
ion.
We
are
not r
equir
ed to
agr
ee to
thes
e ad
dition
al re
strict
ions,
but if
we
do, w
e wi
ll abid
e by
your
agr
eem
ent (
exce
pt in
an
emer
-ge
ncy)
.
Alte
rnat
ive
Com
mun
icat
ion;
You
hav
e th
e rig
ht to
requ
est t
hat w
e co
mm
unica
te w
ith yo
u ab
out y
our h
ealth
info
rmat
ion b
y alte
r-na
tive
mea
ns o
r to
alter
nativ
e loc
ation
s (Yo
u m
ust m
ake
your
requ
est in
writ
ing.)
You
r req
uest
mus
t spe
cify t
he a
ltern
ative
mea
ns
or lo
catio
n, a
nd p
rovid
e sa
tisfa
ctory
exp
lanat
ion h
ow p
aym
ents
will b
e ha
ndled
und
er th
e alt
erna
tive
mea
ns o
r loc
ation
you
requ
est.
Amen
dmen
t; Y
ou h
ave
the
right
to re
ques
t tha
t we
amen
d yo
ur h
ealth
info
rmat
ion.
(You
r req
uest
mus
t be
in wr
iting,
and
it m
ust
expla
in wh
y the
info
rmat
ion sh
ould
be a
men
ded.
) W
e m
ay d
eny y
our r
eque
st un
der c
erta
in cir
cum
stanc
es.
Elec
troni
c No
tice:
If y
ou re
ceive
this
Notic
e on
our
Web
site
or b
y elec
tronic
(e-m
ail),.
You
are
ent
itled
to re
ceive
this
Notic
e in
writte
n fo
rm.
QUE
STIO
NS A
ND C
OM
PLAI
NTS
If yo
u wa
nt m
ore
infor
mat
ion a
bout
our
priv
acy p
racti
ces o
r hav
e qu
estio
ns o
r con
cern
s, ple
ase
cont
act u
s. If
you
are
conc
erne
d th
at w
e m
ay h
ave
violat
ed yo
ur p
rivac
y righ
ts, o
r you
disa
gree
with
a d
ecisi
on w
e m
ade
abou
t acc
ess t
o yo
ur h
ealth
info
rmat
ion or
in
resp
onse
to a
requ
est y
ou m
ade
to a
men
d or
restr
ict th
e us
e or
disc
losur
e of
your
hea
lth in
form
ation
or t
o ha
ve u
s com
mun
icate
wi
th yo
u by
alte
rnat
ive m
eans
or a
t alte
rnat
ive lo
catio
ns, y
ou m
ay co
mpla
in to
us u
sing
the
cont
act in
form
ation
liste
d at
the
end
of
this
Notic
e. Y
ou a
lso m
ay su
bmit a
writ
ten
com
plaint
to th
e U.
S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervic
es.
We
will p
rovid
e yo
u wi
th th
e ad
dres
s to
file yo
ur co
mpla
int w
ith th
e U.
S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervic
es u
pon
requ
est.
We
supp
ort y
our r
ight t
o th
e pr
ivacy
of y
our h
ealth
info
rmat
ion.
We
will n
ot re
talia
te in
any
way
if yo
u ch
oose
to fil
e a
com
plaint
with
us
or t
he U
.S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervic
es.
Cont
act O
fficer
:
Telep
hone
:
Fa
x:
E-m
ail:
Addr
ess:
HIP
AA O
FFIC
ER
carin
gden
tal@
mob
ilede
ntis
ts.c
om88
8-83
3-84
4188
8-33
0-43
31
ELLI
OT
P. S
CH
LAN
G, D
DS
- GEN
ERAL
DEN
TIST
, DEN
TAL
DIR
ECTO
R
Andr
ew F
radk
in, D
DS, J
erry
Hal
pern
, DDS
, Bar
ry H
echt
, DM
D, U
zma
Khan
, DDS
, Hel
en N
ahou
raii,
DMD,
Mel
issa
Rodg
ers,
DM
D, W
illiam
Ste
rn, D
DS
31-0
0 47
th A
ve.,
Box
12, L
ong
Isla
nd C
ity, N
Y, 1
1101
