Privacy Act

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HIPAA Notice of Privacy Form

Effective November, 9, 2015

Patient privacy is important to the doctors and staff of Frederick KiDDS Pediatric Dentistry. Our office is required by law to maintain the privacy of Protected Health Information (PHI) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. PHI is information that identifies you and relates to your past, present, or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (Notice) explains how we may use and disclose PHI to provide treatment, payment or health care operations and for other purposes permitted or required by law. Also, this Notice describes your rights with respect to PHI about you.

Our office is obligated to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.

Examples of How We May Use and Disclose PHI
The following describes how we use your PHI:

We will use PHI for treatment. We may use and disclose PHI about you to provide, coordinate or manage your health care services. Example: Should a prescription be needed to treat a patient in the office, your PHI may be disclosed to a Pharmacist.

We will use PHI for payment. We may give PHI about you to others to bill and collect payment for treatment provided to you. Example: Your PHI will be used in billing your insurance company for treatment rendered in our office.

We will use PHI for health care operations. We may use and disclose PHI in performing business activities. Example: We routinely conduct in office chart audits to ensure correctness of billing. We are also likely to disclose PHI for the following purposes without a written consent.

Business associates: We contract other companies to perform services in our office. These companies may have access to PHI in assisting us. In order to protect your PHI, we require all business associates to appropriately safeguard the information. Example: We contract an outside company to provide us with technical support on our computer system. In assisting us with maintaining our systems, this company has access to PHI.

As require by law: We must disclose PHI about you when required to do so by law. Any other uses and disclosures will be made only with your written authorization.

Your Health Information Rights
You have the following rights pertaining to your PHI:

Obtain a paper copy of the Notice upon request. You may request a paper copy of this Notice, or any revised Notice at any time.

Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to our Privacy Officer. We are not required to agree to those restrictions.

Inspect and obtain a copy of your PHI. You have the right to see a copy of PHI about you contained in a designated record set for as long as our office maintains the PHI. The designated record set may include billing, charting and xrays. We may charge a reasonable fee for copying and mailing such records.

Request an amendment of PHI. If you feel the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request and amendment for as long as we maintain the PHI. To request an amendment to your PHI, contact our office. You must include supporting reasons for the amendment. In certain cases, we may deny your request for amendment. If our office denies your request, you have the right to file a statement of disagreement, and we may give rebuttal to your statement.

Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosure we have made of PHI about you on or after November 9, 2015, for most purposes other than treatment, payment or health care operations. The accounting may exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, and disclosures to friends and family members involved in you or your child’s care. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations. To request an accounting, you must submit your written request to our Privacy Officer. Your request must specify the time period for which you wish to obtain accounting, which may not exceed six years. The first accounting your request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved, if any, and you may choose to withdraw or modify your request at that time.

Request communications of PHI by alternative means or at alternative locations. You have the right to request to receive communications of PHI by alternative means. For example, you may want recall cards sent to a post office box instead of your home address. Your request must be made in writing. If we cannot communicate with you using these alternative means, we may resort to using other contact information we have.

Incidental Disclosures

The Open Bay. We use an open bay in our office for most dental treatment. This type of environment is used for many reasons including positive behavior reinforcement (kids seeing other kids behaving well). Parts of dental treatment and/or conversations may be overheard by other patients or parents in the office. If you find that your child needs additional privacy, please request treatment in the Private Operatory. Be aware that scheduling for that room may be limited as we have only one private treatment operatory in the office.

Appointment Reminder by text, email, or telephone. Also as a general practice we send text messages or emails to the parent or guardian’s phone or email address reminding them of their upcoming appointments. This is usually done four days before each dental appointment. A phone call may be made if an appointment is not confirmed by others methods. Please let us know if you do not want us to contact you in this manner.

Post Operative Calls. Frederick KiDDS Pediatric Dentistry may call the parent or guardian’s phone to update the status of our patient’s after treatment. This call may occur in the evening of or the day following treatment. Please let us know if you do not want to be contacted after patient treatment.

For More Information or to Report a Problem
Contact our Privacy Officer:

Bethany L. Reid
211 Shorebird St.
Suite B
Frederick, MD 21701

  • By entering my name, I agree that I have read the HIPAA Notice of Privacy Form.

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Financial and Missed Appointment Policies

Appointments -48 hours notice is required to cancel appointments. Missed appointments and same day cancellations will be assessed a $50 fee payable immediately. Frederick KiDDS Pediatric Dentistry reserves the right to reschedule your appointment if you are more than 10 minutes late. We understand that conflicts occur however the more notice given the better chance we have to appoint another child in need of care. The office will allow two no show or same day cancellations. After that will provide emergency care only for 30 days to allow you time to find a new dentist. We ask that you respect our schedule as we do yours by seeing our patients in a timely manner.

SelfPay Patients – Payment in full is required at the time services are rendered.

Medicaid Dental Insurance – It is your responsibility to confirm your eligibility. If at the time of service you are not eligible for benefits you will be responsible for all charges.

Assignment of Benefits – The practice will accept assignment of benefits if all the pertinent information is provided prior to the appointment and the insurance company will accept assignment to the dentist.

Patients with Insurance – Your insurance policy may or may not follow the American Academy of Pediatrics dentistry guidelines. IT IS YOUR RESPONSIBILITY TO KNOW YOUR OWN COVERAGE. If you do not want us to provide the recommended standard of care for your child it is your responsibility to notify us. As a courtesy we will file your claim any estimate given to you by the practice is purely an estimate and is due at the time of service. Insurance companies do not guarantee any payment until they have received the claim reviewed it and processed it according to the specific policy terms. If there is a balance after the insurance payment is received a bill will be generated and sent to you for immediate payment. If the claim of not been paid by the insurance company in 45 days we require you to pay the balance using one of the approved payment methods.

Payment Methods – We accept cash, personal checks, Visa, MasterCard, Discover, and American Express. All items returned for non sufficient funds are subject to a $25 fee.

Balances – Any account that still has a balance after 30 days will receive a billing statement from Frederick KiDDS Pediatric Dentistry. After 45 days any accounts with a balance will receive a courtesy phone call. Frederick KiDDS Pediatric Dentistry is able to process credit card payments over the phone to assist you in clearing any balance as you may have. Please call us at 301-202-5041 for help with this matter. Once attempts have been made by phone and there is no response to courtesy call, a “15 days to pay” letter will be sent. If there is no response to the letter the account may be sent to a third party collection agency. You will be responsible for any costs incurred to collect including, but not limited to, collection agency fees, attorney fees, and court costs.

  • By entering my name, I agree that I have read the Financial and Missed Appointment Policies.

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Consent for Dental Procedure and Acknowledgement of Receipt of Information

  • Informed Consent for Dental Cleaning and Exam

  • Please read this form carefully. I hereby authorize and direct Dr. D’Audra M. Cole, assisted by dental auxiliaries, to perform upon my child (or legal ward for whom I am empowered to consent) the following dental procedures:

    In general terms the dental procedures will include:

    • Cleaning of the teeth
    • Dental examination
    • Use of patient behavior management techniques to help safely accomplish the dental procedure when necessary.

    I also authorize Dr. D’Audra M. Cole to use photographs, radiographs, other diagnostic materials and treatment record for the purpose of teaching, research and scientific publications.

    I understand further that I have the right to be provided with answers to questions, which may arise during the course of my child’s treatment.

    I understand that I am free to withdraw my consent to treatment at any time and that this consent will remain in effect until such time that I choose to terminate it.

  • Informed Consent for Fluoride Varnish

  • Fluoride is effective in preventing and reversing the early signs of dental caries (tooth decay). Researchers have shown that there are several ways through which fluoride achieves its decay preventive effects. Fluoride incorporates into the tooth structure making it stronger resulting in teeth that are more resistant to acid attacks. Fluoride also acts to repair or remineralize areas in which acid attacks have already begun.

    Fluoride application is an important part of your child’s comprehensive preventative program at Frederick KiDDS Pediatric Dentistry. Fluoride not only helps prevent new decay from developing, it also helps protect existing dental work so that fillings are replaced less frequently, decreases sensitivity, makes teeth last longer and saves you money! Fluoride is most effective when applied after the dental cleaning after all the plaque and build up have been removed from the tooth’s surface. It is our office protocol to apply fluoride varnish at each routine care appointment for your child to receive maximum benefit.

    In April of 2018 the National Toxicology Program published a study in the scientific journal entitled Neurotoxicity Research which stated that “Researchers found no link between fluoride exposure and adverse health effects.The study, sponsored by the NTP, headquartered at the National Institute of Environmental Health Sciences of the National Institutes of Health, reported no observed fluoride exposure-related differences in motor, sensory or learning and memory performance in rats. Researchers also found no exposure-related pathology in the heart, liver, kidney, testes, seminal vesicles or epididymides.”

    Fluoride varnish is formulated to stick to tooth surfaces to avoid swallowing preventing toxicity and upset stomach. Occasionally children may feel nauseous due to the flavor of the fluoride varnish.

    It is your choice whether or not to have fluoride placed for your child during their dental cleaning appointments. Please indicate your choice below and let the dentist, hygienist, or staff member know if you change your mind at any time.

  • Informed Consent for Dental X-rays

  • Dental x-rays allow the dentist to diagnose and treat conditions that cannot be detected during a clinical examination. Dental x-ray films detect much more than cavities. For example, x-rays may be needed to assess erupting teeth, diagnose bone diseases, evaluate the results of an injury, or plan orthodontic treatment. If dental problems are found and treated early, before they become visible or painful, dental care is much more comfortable and affordable. Dental x-rays are a part of a comprehensive oral examination.

    Per the recommendation of the American Academy of Pediatric Dentistry, Bitewing x-rays (cavity detecting x-rays) are recommended every 6-12 months for a patient with dental cavities or at increased risk for cavities or at 12-24 months for patients with no history of dental cavities where interproximal (in between) tooth surfaces are not visible. Select periapical x-rays may be taken to address specific problems such as pain, unerupted teeth, injury, etc. Additionally, a panoramic (growth and development) x-ray may be taken between the ages of 4-12 years and possibly between the ages of 14-20 when imaging of wisdom teeth is needed. The dose of radiation is minimal from dental x-rays, and all necessary precautions will be taken to ensure exposure is minimal (lead apron, collar and digital imaging).

    It is the policy of Frederick KiDDS Pediatric Dentistry to examine each child and identify their individual need for dental imaging. You have the right to refuse dental x-rays for your child. Frederick KiDDS Pediatric Dentistry reserves the right to dismiss any patient or family that denies necessary dental x-rays after three refusals as this limits the ability of the dentist to identify and diagnose any dental conditions. No dental treatment will be completed without dental x-rays. It is at the discretion of the dentist to treat if the patient is unable to cooperate for dental x-rays and exceptions can be made in such cases. Also, dental x-rays received from a previous office may not always be diagnostic or useful, they can even be blurry or inappropriate for the patient’s age or dental treatment needs. In those instances new x-rays may need to be taken.

    It is your choice whether or not to have dental x-rays for your child Please indicate your choice below and let the dentist, hygienist, or staff member know if you change your mind at any time.

  • By entering my full name, I agree to consent.

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Pediatric Dentistry Informed Consent For Patient Management Techniques

Please read carefully and feel free to ask about anything on this form. We will be happy to explain it further.

It is our intent that our dental care delivery be the best quality available. We are highly experienced in helping children overcome anxiety and we ask that you allow your child to accompany us through the dental experience. Dental anxiety is not uncommon in children so please try not to be concerned if your child exhibits some negative behavior; this is normal and will soon lessen with time, Studies and experience have shown that most children react more positively when permitted to experience the dental visit in an environment designed for children.

Every effort will be made to obtain your child’s cooperation through warmth, charm, humor, and understanding. When these fail, there are several behavior management techniques our office uses to minimize disruptive behavior. The techniques used are recommended by the American Academy of Pediatric Dentistry and are described below.

  • Tell-Show-Do: The dentist or assistant first explains to the child what is to be done, then demonstrates on a model or the child’s finger. Finally, the procedure is completed on the patient’s tooth. Praise is used to reinforce cooperative behavior.
  • Positive Reinforcement: This technique rewards the child who displays any desirable behavior. The rewards include compliments, praise, or a prize.
  • Voice Control: The attention of a disruptive child is gained by changing the tone, increasing, or decreasing the volume of the practitioner’s voice.
  • Mouth Props: A rubber device is gently placed in the child’s mouth to prevent either intentional or unintentional closure on the dentist’s fingers or drill.
  • Physical Restraint By Dental Team: The child is held by the doctor and dental assistant (sometimes with the help of a parent or guardian) so they cannot grab a moving drill or sharp object. They are not able to grab the practitioner’s hand while delicate work is being performed. This is for the safety of the child and to facilitate treatment.


  • Laughing Gas: Nitrous oxide (Laughing gas) is administered to calm and soothe the patient prior to a dentalprocedure. Nitrous oxide is a very safe medication that on rare occasion may cause nausea.
  • Oral Sedation: The oral medication, Versed is administered to calm and relax the patient prior to receiving dental treatment. We ask that your child not eat for six hours prior to the procedure.
  • Physical Restraint by Pillowcase Arm Restriction “Superhero Cape”: The patient’s arms are inserted in a pillowcase behind the child’s back and then the child is laid on top of the pillowcase so that their arms are restrained for their safety.

The above listed pediatric dentistry behavior management techniques have been explained to me, I understand their use, and risks/benefits/alternatives available. I have had all my questions answered and I realize I can always seek further information or revoke permission for any of these techniques.

  • By entering my name, I agree to consent.

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