Intake Form

Responsible Party Information

In case of emergency please contact:

Welcome to Brooklyn Blvd Dental! Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining important health treatment. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the payment options listed below:

Subscribers

Insurance

Employer

* For dental work over $200.00. a current credit card number and expiration date is required. We will not carry an account balance past 90 days.

COVID-19 SCREENING FORM

By signing this form I consent to the following:

1. I have not had or have been diagnosed with COVI D-19 in the last 14 days.

2. I do not have any of the following symptoms linked to COVID-19 listed below:

3. I have not been in contact with anyone sick and/or confirmed to be positive with COVID-19.

4. I have not traveled to any regions affected by COVID-19 in the past 14 days.

HIPAA Acknowledgement

I understand that I have certain rights to privacy regarding my protected health information.

These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

• Obtaining payment from third party payers (e.g., my insurance company);

I have also been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA.

I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.