New Patient Forms

I certify that I, and/or my department(s), have insurance coverage with the above insurance company and assign directly to Dr. Henry Ward all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named dentist may use my health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

(Specify someone who does not live in your household).

Our Pledge Regarding Medical Information
This notice describes our policy regarding the use of your medical information. All physicians, employees, staff and other authorized personnel who may need access to your medical information are bound by this policy.

We are required by law to 1) keep medical information that identifies you private; 2) give you notice of our legal duties and privacy practices with respect to medical information about you; 3) follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information About You
There are different ways that, by law, we may use and disclose medical information. Here are several examples:

• For treatment.
• For health care purposes.
• For notifying you of treatment alternatives.
• For individuals involved in your care or payment for your care.
• To avert a serious threat to health or safety.
• To military officials if you are in the military or are a veteran.
• For health oversight activities.
• For law enforcement.
• To Coroners, Medical Examiners and Funeral Directors.
• For protective services for the President, National Security and Intelligence Activities.
• For payment.
• For appointment reminders.
• For health-related benefits and services.
• For research (under certain circumstances).
• As required by law.
• For worker’s compensation claims.
• For lawsuits and disputes.
• To Prison officials of patients who are inmates.

There is a description of each of the above in the full version of this notice.

Rights Regarding Medical Information About You
You have rights regarding medical information we maintain about you:

• Right to inspect and copy.
• Right to amend.
• Right to an accounting of disclosures.
• Right to a paper copy of this notice both in summary and in complete version.
• Right to request restrictions.
• Right to request confidential communications.

Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our medical practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our medical practice, please contact our Privacy Officer at 8390 Delmar Blvd., Suite 1001, St. Louis, MO 63124, (314) 997-1118. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

• I have read this summary but do not wish to read the full version.
• I have read this summary and the full version.
• I have requested and received a copy of the summary.
• I have requested and received a copy of the full version.