EMPLOYMENT INFORMATION - SELF
MEDICAL HISTORY: (click yes or no and fill in the blanks where required)
DENTAL HISTORY (click yes or no and fill in the blanks where required)
I acknowledge full responsibility for all charges incurred regardless of insurance coverage. A service charge of 1 1/2% per month (18% per
annum) on the unpaid balance will be assessed to all accounts exceeding sixty (60) days from the date of service unless previously written
financial arrangements are made. I understand that the fee estimate listed for this dental care can only be extended for a period of six (6)
months from the date of the patient examination.
In consideration for the professional services to be rendered to me , by the dentist, I agree to pay the fees charged for the dental services
provided by the dentist or his/her assignee. I further agree to pay the remaining balance plus reasonable attorney fees, court costs and a
collection agency commission of 40% if the account is assigned to a collection agency or attorney. I authorize the release of financially
identifiable information concerning my account, including charges billed, payments made, and interest charges assessed, etc. to the
dentist’s collection agency or collection attorney should collection procedures as describe become necessary.
I grant my permission to you or your assignee to telephone me at home on my cell or at my workplace to discuss matters related to this
form. I also agree to let this office leave messages concerning appointments and /or results on my answering machine or with a family
I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information, either
electronically, by facsimile or in paper form to my insurance carrier or my related entities that require such information to be submitted.
I acknowledge that I have received a copy of this office’s Privacy Polices. I agree to disclose to the dentist names of any individuals with
whom I authorize the dentist to discuss my dental care.
I certify that I have answered all questions accurately and to the best of my knowledge. I hereby agree to abide by the conditions outlined herein.
For Dr. Charles B. Jackson, Jr., D.D.S., M.S.D., P.C.
669 E. Union Square
Sandy, UT 84070
2964 W 4700 S #103
WVC, UT 84118
2200 E 4500 S #250
Holladay, UT 84117
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 protected health information (i.e., individually identifiable information, such as names, dates, phone/fax
numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed
by us in one or more of the following respects:
- To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
- To third party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
- To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics’, state dental
boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who have any role in your treatment;
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
- To your family and close friends involved in your treatment;
- We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your
written authorization, which you have the right to revoke.
Under the new privacy rules, you have the right to:
- Request restrictions on the use and disclosure of your protected health information;
- Request coreferential communication of your protected health information;
- Inspect and obtain copies of your protected health information through asking us;
- Amend or modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected health information; and,
- You may without risk of retaliation, file a complaint as to any violation by us of your privacy rights with
us (by submitting inquires to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
Please note that we are not obligated to:
- Honor any request by you to restrict the use or disclosure of your protected health information;
Amend your protected health information for example, it is accurate and complete¡ or,
- Provide an atmosphere that is totally free of the possibility that your protected health information may
be incidentally overhead by other patients and third parties.
l HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED AND REVIEWED A COPY OF THE PRIVACY
In case you do not agree to sign this form, you must indicate why you declined to do so.