3103 Big Trail Drive, Jackson, WY

307-733-4778

Monday - Friday

Welcome to All Our New Patients!

We're happy to have you! For your convenience and to ensure a smooth check-in process, new patients can fill out the forms on this page prior to their first visit conveniently online.

Note: be sure to call us to make an appointment.

New Patient Registration

Please fill in the following information. Your answers are for our records only and will be kept strictly confidential subject to applicable laws. Please note that you will be asked some questions concerning your health. This information is vital to allow us to provide you the best care possible.

General Information

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Contact Information

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Dental Information

Medical History

For Women Only

HIPAA CONSENT FORM AND PRIVACY POLICIES


PLEASE READ THE FOLLOWING CAREFULLY:

PURPOSE OF CONSENT:

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment,
payment activities and healthcare operations.

NOTICE OF PRIVACY PRACTICES:

You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our
notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice can be found at the front desk when asked. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. If you decide to pay for your treatment in full on the date of service and do not want your insurance to be billed, you have the right to request not to disclose treatment information for this service to a health plan. If applicable, a patient has the right to an Electronic copy of their records if they prefer. YOU MAY OBTAIN A COPY OF OUR Notice of Privacy Practices, INCLUDING ANY REVISIONS OF OUR NOTICE, AT ANY TIME, BY CONTACTING US.

RIGHT TO REVOKE:

You will have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that WE MAY DECLINE TO TREAT YOU OR TO CONTINUE TREATING YOU if you revoke this consent.

Authorization and Release of Records
I authorize Larsen Family Dentistry to release any information, including the diagnosis and the records of any treatment or examination
rendered to me or my child during the period of such dental care, to third party payers and/ or health practitioners. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree to allow Larsen Family Dentistry to leave messages concerning my appointments and/ or results on my answering machine or with family members.

Payment Policy

  • Payment is expected at the time the service is rendered. We will accept Cash Personal checks The following Credit Cards: Visa MasterCard DiscoverCard

  • Non-insured patients are expected to make payment in full on the day the service is rendered, unless definite arrangements have been made with our office manager PRIOR TO TREATMENT.

  • Patients with dental insurance are expected to pay the portion of the total fee not covered by their insurance on the day of service. The “Patient Portion” is ONLY an estimated dollar amount. DUE TO HIPAA, WE ARE NOT ABLE OR ALLOWED TO GATHER ANY INSURANCE INFORMATION FROM A 3RD PARTY. IT IS THE RESPONSIBILITY OF THE PATIENT TO HAVE FULL INFORMATION AT THE DATE OF SERVICE OR THE PATIENT WILL BE EXPECTED TO PAY THE FULL AMOUNT. AS A COURTESY, our office will file your claim with your insurance company, and initiate correspondence with the purpose of getting you the maximum coverage your insurance will allow; however, if we do not receive payment from your insurance company within 60 days, the payment becomes your responsibility.

  • It is the PATIENT’S responsibility to know and understand his/ her insurance coverage. Larsen Family Dentistry will be happy to give you the number of your insurance company to contact them with further questions.

  • The patient is ALWAYS responsible for seeing that the ENTIRE FEE is paid in full.

  • If payment is not taken care of by the insurance or the patient within 90 days, there will be a fee added to the account, and the account will be sent to Collections.


Reminder Policy

  • AS A COURTESY, Larsen Family Dentistry gives reminders of the patients’ appointments via mail and phone. However, it is the patient’s responsibility to remember their appointments and be on time. It is not the responsibility of the office if the patient does not receive the reminders and forgets his/ her appointment, which will result in a failed appointment fee.


Cancellation Policy

To achieve the highest level of patient care and time management, our office requires appointment changes to occur within the office hours (7:00am to 3:00pm) the day before (24 hours) the appointment date. Failure to do so will result in a $50.00 failed appointment fee.

I authorize Larsen Family Dentistry to use my phone number and email address to send me healthcare and marketing messages, e.g. appointment reminders, new services, events, or special offers. I know I have the right to opt out or unsubscribe whenever I choose.

AS A PATIENT/ RESPONSIBLE PARTY AT LARSEN FAMILY DENTISTRY I UNDERSTAND AND AGREE TO THE ABOVE POLICIES

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and health care operations.
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Please read the above, and understand that the information provided in this form is accurate. A truthful health history will help ensure the best possible dental treatment. The information provided here will be used by the doctor and patient to inform any further discussion of the patient's health prior to or during an appointment. By signing below you also acknowledge that you will not hold the dentist, the dental practice or any other member of the practice staff responsible for any action or lack of action because of errors or omissions that may have been made during the completion of this form.
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Notice of Privacy Practices


This notice describes how health information about you may be used and disclosed and how you can get access to this information.Please review it carefully. The privacy of your health information is important to us.

Our Legal Duty

We are required law to maintain the privacy of your protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/23/2013, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

How we may use and disclose Health Information about you

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing and credentialing activities.

Individuals Involved in Your Care or Payment for Your Care

We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Required By Law: We may use or disclose your health information when we are required to do so by law.

Public Health Activities: We may use or disclose your health information for public health activities, including disclosures to:

  • Prevent or control disease, injury or disability;
  • Report child abuse or neglect;
  • Report reactions to medications or problems with products or devices;
  • Notify a person of a recall, repair, or replacement of products or devices;
  • Notify a person who may have been exposed to a disease or condition; or
  • Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.

Secretary of HHS: we will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation: we may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities: we may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in a response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors: we may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising: We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

OTHER USES AND DISCLOSURES OF PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or has otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

YOUR HEALTH INFORMATION RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contract information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $0.00 for each page, and $0.00 per hour for staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation for our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before 2007. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Disclosure Accounting: with the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction: You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying our payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Right to Notify of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by e-mail.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Larsen Family Dentistry

Contact Officer: Scott C. Larsen, D.M.D. or Isabel Bradford

Telephone: 307-733-4778

Fax: 307-734-8041

E-mail: teeth@lfdds.com

P.O. Box 4935

245 East Broadway

Jackson, Wy 83001