For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure.



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FINANCIAL POLICY For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure. METHODS OF PAYMENT Acceptable methods of payment are cash, check, Visa, Mastercard or debit cards. We offer a 5% discount if you pay in full by cash or check at the time of service. If you wish to pay in full at the time of service with a credit card, we will offer a 3% discount. Charges not paid at the time of service are due within 30 days. INSURANCE As a courtesy, we will bill your insurance company for you if provided with all the proper billing information. All accounts are due within 60 days, regardless of insurance involvement. A 1.5% monthly finance charge will be assessed on all accounts past 60 days. You will receive a monthly statement regarding your account activity. estimates We can provide a treatment plan with an estimate of total fees after the initial visit. This treatment plan will also include, in writing, a breakdown of our fees, the estimated insurance coverage, and your portion that will be due at each visit. We would like to emphasize that these are estimates. Should additional unforeseen problems or complications arise as treatment progresses, you will be kept informed. PAYMENT OPTIONS Please feel free to discuss payment options with our staff. We offer several plans that will help you with financial planning. CANCELLATION POLICY There may be a $50 fee for an appointment that is cancelled with less than 48 hours notice. 600 Broadway Suite 330 Seattle, WA 98122 206.325.0166 dentalcareseattle.com

WELCOME TO OUR PRACTICE 600 Broadway Suite 330 Seattle, WA 98122 206.325.0166 smiles@dentalcareseattle.com Office hours Monday 8 a.m. to 5 p.m. Tuesday 7 a.m. to 5 p.m. Wednesday 8 a.m. to 5 p.m. Thursday 8 a.m. to 5 p.m. Friday 7 a.m. to 3 p.m. Parking Parking is available in our building, with access at the bottom of Cherry Street on the North side. Street parking is also available on two hour parking meters on each street surrounding our location. Appointments We know there are times when you cannot keep your appointment. If this happens, we require 48 hours notice so we may utilize this time for another patient. WEB PAGE Please check our web page dentalcareseattle.com for answers to most of your questions. In addition, you can print out the registration and health history forms from our web site and bring them with you to your first appointment. Please call us for any further questions. BROADWAY E UNION ST BOREN AVE MADISON ST Seattle University E CHERRY ST (James turns into Cherry) CHERRY ST JAMES ST 12TH AVE W N S E MADISON ST Cherry street deadends, with parking under our building. 600 Broadway Suite 330 Seattle, WA 98122 dentalcareseattle.com E YESLER WAY CHERRY ST S JACKSON ST AMES ST CHERRY ST JAMES ST BROADWAY 2TH AVE

ACKNOWLEDGEMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICES I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dental Care Seattle. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Dental Care Seattle reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (PLEASE SPECIFY) YES NO Name of Patient or Personal Representative Signature of Patient or Personal Representative Date Description of Personal Representative s Authority

STATEMENT OF PRIVACY PRACTICES Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights. PROTECTING YOUR PERSONAL HEALTH INFORMATION We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone even family members without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released. COLLECTING PROTECTED HEALTH INFORMATION We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail, answering machines, and postcards. PATIENT RIGHTS You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. We thank you for being a patient in our practice. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information. 600 Broadway Suite 330 Seattle, WA 98122 206.325.0166 dentalcareseattle.com

PATIENT HEALTH HISTORY Name Employer/Occupation Physician/Location Are you allergic to: Penicillin? Codeine? Latex? Other allergies? Current medications? (Women) Are you pregnant? Do you have a history of any of the following? Please check: Artificial heart valve Heart surgery Heart disease Heart murmur Pacemaker Diabetes Radiation treatment HIV Prolonged bleeding Other? Cancer/tumor Bis-phosphonates Artificial joint Diet drugs Anemia Hepatitis/liver disease Sinus trouble Surgery Sleep disorder Epilepsy Glaucoma Asthma High blood pressure Ulcers T.B. or lung disease Arthritis Tobacco use Thyroid disorder Comments: OVER

600 Broadway Suite 330 Seattle, WA 98122 206.325.0166 PATIENT REGISTRATION Date: preferred name: NAME SEX CHILD SINGLE M F MARRIED OTHER SPOUSE S NAME/PARENT S NAME (IF MINOR) YOUR SOC. SEC. # BIRTH DATE HOME PHONE ADDRESS CITY ZIP CELL PHONE WHO REFERRED YOU? EMPLOYER OCCUPATION WORK PHONE YOUR EMAIL ADDRESS EMERGENCY CONTACT (OTHER THAN SPOUSE) Insurance Information PRIMARY DENTAL INSURANCE GROUP #/EMPLOYER NAME OF SUBSCRIBER (OTHER THAN SELF) BIRTH DATE INS. ID # OR SEC. SEC. # SECONDARY DENTAL INSURANCE GROUP #/EMPLOYER NAME OF SUBSCRIBER (OTHER THAN SELF) BIRTH DATE INS. ID # OR SEC. SEC. # MY PRIMARY PREFERENCE FOR COMMUNICATION: TEXT EMAIL PHONE I have read Dental Care Seattle s financial policy. (initials) I am financially responsible for my own account. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. If insurance coverage exists, I authorize payment to go directly to my dentist. SIGNATURE DATE OVER

PATIENT HEALTH HISTORY Name Employer/Occupation Physician/Location Are you allergic to: Penicillin? Codeine? Latex? Other allergies? Current medications? (Women) Are you pregnant? Do you have a history of any of the following? Please check: Artificial heart valve Heart surgery Heart disease Heart murmur Pacemaker Diabetes Radiation treatment HIV Prolonged bleeding Other? Cancer/tumor Bis-phosphonates Artificial joint Diet drugs Anemia Hepatitis/liver disease Sinus trouble Surgery Sleep disorder Epilepsy Glaucoma Asthma High blood pressure Ulcers T.B. or lung disease Arthritis Tobacco use Thyroid disorder Comments: OVER

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