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Personal Information
Medical History
Authorization Form
Notice of Privacy Practices

Personal Information

Personal Information

    • Guarantor's Information (Parent or Legal Guardian)

    • Other Parent or Guardian's Information

 

PRIMARY INSURANCE

 

SECONDARY INSURANCE

 

Medical History

Medical History

  • By signing you are: consenting to treatment of your child, authorizing release of any information relating to dental claims, accepting responsibility for all costs of dental treatment and authorizing insurance payment to be made directly to Valleau, VanDeven, and Massie DDS PC.
 

Authorization Form

Authorization and Consent to Send Unencrypted Patient Information by Email and Other Electronic Means

  • Until I tell you in writing to stop, I authorize Valleau, VanDeven, and Massie DDS PC to transmit patient information relating to my treatment, health, or payment by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment, or Valleau, VanDeven, and Massie’s health care operations.


    I understand that:
    • I do not have to sign this form.
    • My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.
    • If I don’t sign this form, Valleau, VanDeven, and Massie’s may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.
    • There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by privacy law.
    • Valleau, VanDeven, and Massie’s does NOT email such sensitive personal information such as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

    I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that Valleau, VanDeven, and Massie’s already sent before receiving my written instructions to stop.
 

Financial Policy

  • Aimee C. Valleau D.D.S.
    Christopher E. VanDeven D.D.S.
    Jessica C. Massie D.D.S.
    Dentistry for Children
    2000 43rd St SE,
    Suite B
    Grand Rapids, MI 49508
    Ph: (616) 455-1301

    Thank you for choosing Dr. Valleau, Dr. VanDeven, and Dr. Massie as your child’s dental care provider. We are committed to your child’s treatment being successful. Please understand that payment of the bill is considered a part of the treatment. Our insurance and patient finance coordinators will work very hard to make sure your paperwork is filed accurately and promptly.

    The following is a statement of our Financial Policy that we require you read and sign prior to any treatment. By signing this, you are agreeing to pay for all services that are received.

    Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.

    Payment options if you have no insurance: We require payment in full at the time of service unless prior payment arrangements are approved by us in writing. You may pay by cash, check, or credit card. On extensive treatment, you may prefer to secure a bank, credit union, or other third-party financing for the entire amount and make payments to the lending institution.

    Payment options if you have insurance: All insurance deductibles, co-pays and any out-of-pocket portions must be paid in full at the time of service. It is your responsibility to know what your insurance coverage is. If you do not know what percentage is covered by your insurance, we require payment of 20% of the total charges to be paid at the time of service. The balance is your responsibility whether your insurance company pays or not.

    Usual and Customary Rates: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

    Payments: Unless we approve other arrangements in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of the month. Balance must be paid in full before next appointment.

    Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

    Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
    We do not participate with any insurance plans other than Delta Dental Premier and Blue Cross and Blue Shield of Michigan. If your insurance plan is a HMO, DMO, reimbursement plan or will not pay us directly, you are required to pay in full at the time of service and submit claims yourself.

    Minor Patients:The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa/MasterCard, or payment by cash or check at time of service has been verified.

    Required payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.

    Returned checks: There is a fee (currently $25) for any checks returned by the bank.

    Missed appointment fee: We reserve the right to charge patients who do not show up on time for an appointment, or cancel with less than 24 hours notice. This fee must be paid before a new appointment is scheduled. Patients may also be asked to transfer their records to another doctor. Please help us serve you better by keeping scheduled appointments.

    Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. This will include a $20.00 pre-collection fee. If we have to refer your account to a collection agency, you agree to pay all of the collection costs that are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees, which we incur, plus all court costs. In case of suit, you agree the venue shall be in Kent County, Michigan.

    Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

    Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

    Transferring of Records: If you request to have copies of your records sent to another doctor or organization, you authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

    Co-signature: If another person signs this or another Financial Policy, that co-signature remains in effect until canceled in writing. If written cancellation is received, it becomes effective with any subsequent charges.

    Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in force and effect.
 

Notice of Privacy Practices

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 by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect July 14, 2015 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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available 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.

    USES AND DISCLOSURES OF HEALTH INFORMATION


    Treatment: We may use or 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 payment for services we provide to you.

    Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. 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 or credentialing activities.

    Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

    To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

    Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

    Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

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

    Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

    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 of protected health information of inmate or patient under certain circumstances.

    Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

    How We May Send Health Information About You: Your protected health information (PHI) includes information relating to your mental or physical health and to the health care provided to you, including materials like your dental records, dental x-rays, and payment records.

    Sometimes our dental office needs to send PHI to the patient or to someone else, such as a specialist. There are various ways to send PHI, including email or other electronic means. Our dental practice does not encrypt email or other electronic forms of communication. There is a risk that unencrypted information may be acquired by hackers or received by unintended recipients. If you are concerned about the security of PHI that may be sent unencrypted, please let us know and we will send it a different way, which may include providing the information to you to deliver.

    PATIENT 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 contact information listed at the end of this Notice. We reserve the right to charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we reserve the right to charge you a reasonable fee for each page, or per hour for staff time to locate and 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 of 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 April 14, 2003. 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.

    Restriction: 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 additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

    Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation 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.

    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.

    Contact Officer: Aimee C. Valleau D.D.S.
    Telephone: (616) 455-1301 Fax: (616) 455-6533
    E-mail: vvmkentwood@vandvkidsdentistry.com
    Address: 2000 43rd Street SE, Suite B, Grand Rapids, MI 49508

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 
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