New Patient Forms

We are happy to offer our patient forms online. Please Click on the link below to be directed to our Forms/Questionaires page. Please note that these registration forms must be completed and submitted prior to your first dental visit.

Online Patient Registration

HIPPA—Notice of Privacy Practices

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.

The Health Insurance and Portability and Accountability Act of 1996 (HIPPA) is a federal program that requires that all medical and dental records and other individually identifiable health information used or disclosed by us is any form, whether electronically, or on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. Federal law requires us to give you this Notice regarding our privacy practices, our legal duties and your rights concerning your health information.

Our Thoughts about Your Protected Health Information:

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.

As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records in some of, but not limited to, the following categories, each of which provide only a general explanation.


We provide information for coordinating or managing health care and related services by one or more health care providers or, possibly, family members. Examples would include, but not be limited to, progress letters to referring health care practitioners or others involved in your care, laboratories providing services for the practice, pharmacies, and family members or other personal representatives authorized by you or by a legal mandate. Doctors in this office may discuss your treatment among themselves, with referring doctors, or with doctors to whom you have been referred.


We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any other third party, such as family members who are responsible for payment. For example, we may need to give your health care information, about treatment you received at the Practice, to obtain payment or reimbursement for the care. We may also tell your health plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment, to facilitate payment of a referring physician, or the like.

Health Care Operation

This includes the disclosure of information so that we can run our practice more efficiently and make sure that all of our patients receive quality care. This would include activities such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and improvements to or additions to the care and services we offer. This may include monitoring and auditing functions by insurance companies and/or government agencies.

Appointment and Recall Reminders

We may contact you by phone, in writing, or by e-mail, regarding appointments and follow-up visits. This may involve leaving a message by e-mail or on an answering machine, or otherwise, which could (potentially) be received by intercepted by others.

Emergency Situations

A situation where your family, or responsible party, can be notified about your condition, status, and location. This may include disclosing information to an organization assisting in disaster relief efforts.

Required by Law, Government Activities, and Law Enforcement

We will disclose information as required by local, state, or federal law. We may disclose medical information to a local, state, or federal agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the payor, the government and other regulatory agencies to monitor the health care system, government programs, and compliance with civil rights laws. We may disclose information to federal officials for intelligence and national security issues.

We may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process
  • To identify or locate a suspect, fugitive, material witness, or missing person
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
  • About a death we believe may be the result of criminal conduct
  • About criminal conduct at the Practice
  • In emergency circumstances to report a crime; the location of the crime or victims, to the identity, description or location of the person who committed the crime.

Worker’s Compensation

We may release information for worker’s compensation or similar programs.

Public Health Risks

Law or public policy may require us to disclose information for public health activities. An example would be the requirement to report suspected cases of abuse and/or neglect, or reporting reactions to drugs or problems with products or devices.

To Avert a Serious Threat to Health or Safety

We may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone or an organization able to help prevent the threat.

Lawsuits and Disputes

If you are involved in a lawsuit, we may disclose health information about you in response to a court or administrative order. This is particularly true if you make your health an issue in the dispute. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. We may also use such information to defend ourselves, or any member of our Practice, in any actual or threatened action.

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 permissions, unless those uses can be reasonably inferred from the intended uses above. We may create and distribute de-identified health information, such as for research purposes, by removing all references to individually identifiable information. Any other uses and disclosures will be made only with your written authorization. You may revoke this authorization, in writing, and we are required to honor the request, except to the extent that we have already taken actions relying on your 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.

Changes to this Notice

We reserve the right to change this notice at any time. 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 may receive from you in the future. We will post a copy of the current notice in the Practice. Each time you visit the Practice for treatment or health care services you may request a copy of the current notice in effect.

Your Rights As Our Patient:



You have the right to inspect and obtain copies of you health information that may be used to make decisions about your care. Upon proof of appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed. This includes medical and billing records, but there may be limited exceptions where access may be denied (an example would be psychotherapy records). To have your records copied, you must submit your request in writing to our Office.

Right to Amend

You have the right to amend your information if you feel it is incorrect or incomplete. To request an amendment, contact the Office and a request form will be mailed to you. The request must include the amendment and a reason that supports your request to amend. The amendment must be dated and signed by you. We may deny your request if (a) we did not create the information or the entity that created the information is no longer available, (b) is not part of the medical information kept by or for the practice, (c) is not part of the record that you would be allowed to inspect and copy, (d) the information to be amended, is, in our opinion, accurate and complete, and (e) your amended information is inaccurate and/or incomplete.

Disclosure Accounting

You have the right to an “accounting of disclosures” which is a list of the disclosures we made of medical information about you other than for treatment, payment, healthcare operations, and certain other activities. Your request must be in writing and must state a time period no longer than six (6) years prior to the request and may not include dates prior to April 14, 2003.


You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these restrictions and may not be able to comply with your request. But if we do, we will abide by our agreement with you, except in the case of an emergency, if the information is necessary for your treatment, or if the information is required by law. You have the right to revoke a previously agreed upon restriction, at any time, in writing. To request restrictions, you must make your request in writing. In your request, you indicate:

  • What information you want to limit
  • Whether you want to limit our use, disclosure or both
  • To whom you want the limits to apply, (e.g., disclosure to your children, parents, spouse, etc.)

Confidential or Alternative Communication

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing and must specify the alternative means or location for us to contact you. We will accommodate all reasonable requests. In addition, the request must also specify how payments will be handled under the alternative means or location you request.

Copy of This Notice

You have a right to a paper copy of this notice. Even if you receive a copy of this notice electronically, you have a right to a paper copy.

Questions and Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Office. To file a complaint with the Practice, contact our Office at 609.921.0034 and we will direct you on how to fill out an office complaint. All complaints must be submitted in writing and all shall be investigated without repercussion or penalties to you.