Welcome to smiLee!

Taking care of you and your family is our highest priority at smiLee. These policies are very important and exist to foster an environment of clarity and mutual respect. Please take the time to read and understand them. Please contact us with any questions or concerns you may have regarding these policies.

Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Race/Ethnicity:
Address:
City:
State:
Zip:
Phone Number:
Email:
School and Grade:
List any sports, hobbies, or musical instruments played:
Favorite Netflix Show:
How did you hear about us?

Dental History

Please check the following services you are interested in:
What is the patient's dental and/or orthodontic concern?
Dentist Name:
Phone #:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when and where?
Does the patient use flouridated toothpase?
Does the patient brush their teeth 2 or more times per day?
Does the patient floss their teeth daily?
Does the patient sleep with a bottle or breast feed on demand?
Does the patient use a sippy cup?
If yes, please list contents (milk, juice, water, etc.)
Is the patient on a restricted diet? If yes, describe:
What does the patient routinely eat for snacks?
What does the patient routinely drink?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
Discomfort from teeth or gums?
Please explain:
Missing or extra permanent teeth?
Frequent canker sores or cold sores?
Oral habits (thumb or finger sucking, lip or nail biting, grinding, clenching, etc.)?
Please list:
Speech problems or therapy?
Please explain:
Abnormal swallowing (tongue thrust)?
Mouth breathing?
Snores during sleep?
Pain, tenderness, noise or other issue with temporomandibular joint?
Please explain:
Injury to face, jaw, teeth, or mouth?
Please explain:
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Address:
City:
State:
Zip:
Does the Patient need to premedicate prior to dental visit?
Has the patient ever had a hospitalization/surgery? If so, what for?
Any previous issues with anesthesia or sedation? If yes, please explain.
Please list any medications currently being taken by the patient (include non-prescription, vitamins and dietary supplements)
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal (nickel, etc.)
Penicillin
Other
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* Autism spectrum disorder
* Developmental Delay
* Intellectual Disability
* Cerebral palsy
* ADD/ADHD
* Behavioral or emotional disorder
* Impaired hearing/speech
* Damaged or artificial heart valves
* Heart Attack/Stroke
* Congenital Heart Defect
* Heart Murmur
* Hemophilia
* Hypertension
* Prolonged Bleeding
* Anemia
* Lung Disease
* Asthma
* Cystic fibrosis
* Sleep apnea
Snoring
* Tonsils/Adenoids Removed
* Liver Disease
* Kidney Disease
* Endocrine Problems
* Diabetes
* Bone Disorders
* Take Bisphosphonates
* Prosthetic joints
* Arthritis
* Fine motor defects
* Gastroesophogeal reflux disease
* Food allergy or intolerance
* Cancer/history of chemotherapy, radiation, or bone marrow or organ transplant
* HIV/AIDS
* Females: are you pregnant?
* Seizures/Epilepsy
* Hydrocephaly or placement of shunt
Please specify: (ventriculoperitoneal, ventriculoatrial, ventriculovenous
Any other medical issues not listed above, please explain or if any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
Has patient begun puberty?
FEMALES: Has menstruation begun?
Age of 1st period?
MALES: Has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either biological parent ever had orthodontic treatment?

Parent/Guardian Information

Parent/Guardian #1
First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:
Work Phone:
Parent/Guardian #2
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Employer:
Occupation:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Financial Policy

Insurance coverage can be confusing and complex. Our goal is to provide you with clear information regarding our dental fees, your insurance benefits, and available payment options. It is a common misconception that dental insurance is designed to pay for all of your family’s dental care. Most dental insurance plans have deductibles, co-pays, co-insurance, varying degrees of coverage, and yearly maximums that they will pay. The insurance Usual Customary Fee (UCR) and coverage amounts are determined by the plan that you/your employer pay for your policy and that was negotiated with the insurance company. The insurance UCR has nothing to do with the actual charges of smiLee. Our fees at smiLee are based upon a combination of our cost, our time, and our constant dedication to supplying our patients with the highest quality pediatric dental and orthodontic care. The treatment provided at smiLee is never based on what your insurance company will pay, and medical and dental treatment should never be governed by your insurance contract.

At smiLee, we work with you to maximize your dental benefits and receive the best care. It is your responsibility to provide us with the most accurate dental insurance information and update it as necessary. If you provide your insurance information prior to the day of your dental visit, we will be more than happy to help you interpret your dental benefits. Before each dental visit, our goal is to provide you with an estimate of the total fees expected based on your dental coverage. We really strive to prevent unexpected and unforeseen charges. However, please understand that this is only an estimate and actual charges may increase or decrease. Treatment can change for a variety of unforeseen reasons. Whenever possible, we will inform you of any treatment changes that will affect your financial estimate.

Complete payment for services is expected at the beginning of the appointment on the day that treatment is rendered. If your dental plan pays more than expected you will receive a prompt refund. If your dental plan pays less than expected, a balance due will be reflected on your statement. If your dental plan later determines that you were not eligible for coverage, the balance becomes your responsibility. If your insurance has not paid your account within ninety (90) days, the balance will be transferred to your account. In some instances, insurance plans will make payments directly to the member – with these plans, payment in full will be expected on the day that treatment is provided.

Payment Methods:
Cash, Checks, Visa/Mastercard/American Express
Care Credit (pediatric dental services)
In-house 0% financing (full orthodontic treatment)
Payment for deductibles, co-payments, and co-insurance amounts are due at the beginning of the appointment on the same day services are rendered.

Payment is due at time of service. Once treatment is rendered, fees are non-refundable. Balances not paid or payment arrangements not made within the first 60 days of the statement will be sent to a collections agency.

Divorce/Separation: The parent or guardian who brings the child for their initial visit is responsible for payment independent of what a divorce decree or custody arrangement may state. Reimbursement must be made between the divorced parents. We will not intervene.

By signing below:

  • I accept responsibility to pay for any service(s) provided to me that are not covered by my insurance

  • I acknowledge I have read and agree to the terms of this policy

  • I authorize payment of dental benefits billed to my insurance by smiLee Pediatric Dentistry & Orthodontics

  • I authorize smiLee to release all information necessary to secure benefits of payment

Parent/Legal Guardian's Name:
Date:

Media Release

In the office at smiLee and at our sponsored community, family and service events we enjoy actively engaging with our local community. We ask permission take and share photos/videos of you and your family.

I hereby consent for smiLee Pediatric Dentistry & Orthodontics to use, reproduce, exhibit or distribute (in full or in part) any photograph, video, film, and/or audio recordings made of my child or his/her likeness; and/or any written extract of such recordings in which he/she may be included, for any purpose whatsoever, in any medium now known or in the future invented.

I hereby release, discharge, and agree to hold harmless smiLee Pediatric Dentistry & Orthodontics and all persons acting under its permission or authority from any liability or injury that may occur while performing or appearing in the said video, audio, or photographic production.

Please note that even if you consent above to having pictures taken, you may decline on a given day if you’re not feeling particularly “photo-worthy”.

Parent/Legal Guardian's Name:
Date:

Appointment Policy

Dental appointments are excused school absences and we will provide appropriate documentation.

At smiLee, we encourage patients to take their appointments as seriously as we do. An appointment time that is reserved for you and if not kept, leaves other children in need of treatment to wait longer than necessary. Any appointments cancelled less than 48 hours from scheduled appointment time or should you “no-show” to your appointment, a $25 fee will be incurred. After 3 cancellations on short notice (<48 hours) and/or “no shows”, this will result in dismissal from the practice. We do understand that there are emergencies and a 48-hour advance notice may not be possible at all times. We ask that you contact our office as soon as possible to reschedule your appointment. Please be sure to provide us with the best contact phone number to call for reminders of appointments and your e-mail address and update us immediately with any changes.

While we make every attempt to schedule appointments at convenient times for busy families and around hectic schedules, it may not always be possible to accommodate exact appointment date and time requests. Please be mindful that a vast majority of our patients are school age children with similar schedules. Our goal is to provide dentistry that is as pleasant as possible for your child. We value your time by scheduling sufficient time needed for each appointment and it’s very important that you have your child in the office at the time scheduled. If you are more than 10 minutes late, it may be necessary to reschedule your child’s visit.

By signing below, I acknowledge I have read and agree to the terms of this policy.

Parent/Legal Guardian's Name:
Date:

Medical Treatment Authorization and Consent Form

** If the parent or legal guardian will always accompany the child to the appointment, you can skip this section. While we encourage a parent/legal guardian to be present for the child’s first visit to our office, we understand this may not always be possible. If you will not be accompanying your child, this form must be completed and the accompanying adult must provide matching photo ID at the time of the appointment and be completely aware of the child’s medical history. We ask that the parent/legal guardian be available by phone. **

The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This “Medical Treatment Authorization and Consent Form” gives authority to a designated adult to arrange for medical/dental care for a minor. This is extremely important, in that, medical/dental care cannot be provided to a minor without approval by the parents or legal guardians, unless there is written consent authorizing an agent to give approval.

The undersigned do hereby authorize (adult who will accompany minor to dental appointment AND their relationship to the minor) as he/she may designate as agent for the Undersigned to consent to any radiographic, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above named minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and/or surgeon, licensed under the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

As the adult accompanying the minor is authorizing medical/dental treatment, it is very important that they have complete knowledge of any medical conditions, current medications, and existing allergies of the minor. A medical and dental history will have to be filled out and updated each visit on behalf of the minor.

While we strive to provide the most accurate treatment plan cost estimates, sometimes situations arise that necessitate deviations in the treatment plan that may cause the overall cost of treatment to increase or decrease. I authorize the undersigned to make financial decisions and arrangements to cover the cost of treatment rendered.

This authorization is effective as of date signed and will be added to the minor’s records and will remain effective until otherwise requested by parent or legal guardian.

Parent/Legal Guardian's Name:
Date:

Authorization to Release Information

This section is used to obtain authorization to release information regarding you and/or your child covered under the Privacy Act to people other than yourself. I authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself and/or my child(ren).

Parent/Legal Guardian's Name:
Print Name:
Relationship:
Phone:
Print Name:
Relationship:
Phone:
Print Name:
Relationship:
Phone:

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/13/2021 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

Required by Law. We may use or disclose your health information when we are required to do so by law.

Public Health Activities. We may disclose your health information for public health activities, including disclosures to:

o Prevent or control disease, injury or disability;

o Report child abuse or neglect;

o Report reactions to medications or problems with products or devices;

o Notify a person of a recall, repair, or replacement of products or devices;

o Notify a person who may have been exposed to a disease or condition; or

o Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.


National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.

If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Acknowledgement for Receipt of Notice of Privacy Practices

I, , have received a copy of this office's Notice of Privacy Practices.
Patient Name:
Date:

Please let our front desk know if there are any methods of communication provided in this history that are not acceptable to receive protected health information including patient name, diagnosis, date & time of service.