We can’t wait to see you. Before you head into the office, please fill out the following forms. You may also print them and bring them with you on your day of appointment.
WHY?
Federal law requires collection of this information. We will never share your data.
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this form. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time except to extent that you have taken action relying on this content.
WHY?
This information allows us to make your Hometown Family Dental experience as comfortable as possible.
WHY?
Dr. Jackson and our expert dental assistants need this information to smoothly introduce you to our staff and office.
Many of our patients allow family members such as their spouse, parents or others to call and request dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.
Occasionally it is necessary for the staff of Hometown Family Dental to leave messages for patients. The purpose of these messages are to notify the patient that we would like to discuss treatment needs, billing purposes or to ask a patient to call back regarding an issue or concern. To expedite the receipt of the needed information, please indicate below if you would like to give consent to leave detailed messages. Please mark your preference below.
I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above authorized recipient or voicemail or email is no longer protected by federal or state law and may be subject to redisclosure by the above recipient or someone who has access to your voicemail or email. You have the right to revoke this consent in writing.
WHY?
To receive treatment in our office, you must consent to your own dental treatment (and that of your children).
WHY?
Our goal is to provide quality dental care in a timely manner. We ask patients adhere to our cancellation and no-show policy.
CANCELLATION OF AN APPOINTMENT
In order to be respectful of other patients’ needs, please be courteous and call our office promptly if you are unable to attend an appointment. This time will be given to someone who is in urgent need of treatment. We ask that you contact our office two business days (48 hours) in advance to cancel or reschedule your appointment.
NO SHOW POLICY
A ‘no show’ is an appointment that was not cancelled in advance (minimum of 48 hours). No shows inconvenience other patients who need dental care. A ‘no show’ for a scheduled appointment will result in a fee of $25.
LATE ARRIVALS
In an effort to serve our patients in a timely manner, we ask that you are on time for your scheduled appointment, please call the office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule.
Thank you for choosing Hometown Family Dental for your dental needs. We look forward to a long-lasting relationship with you.
ACKNOWLEDGEMENT
My e-signature below indicates that I have read, understand and agree to the appointment policy above.
Or download and print them. And bring them to your appointment.
WHY? Dr. Jackson and our expert assistants need this information to smoothly introduce you to our office.
WHY? Let’s make your Hometown Family Dental experience as comfortable as possible.
WHY? Federal law requires collection of this information. We will never share your data.
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this form. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time except to extent that you have taken action relying on this content.
CANCELLATION OF AN APPOINTMENT
In order to be respectful of other patients’ needs, please be courteous and call our office promptly if you are unable to attend an appointment. This time will be given to someone who is in urgent need of treatment. We ask that you contact our office two business days (48 hours) in advance to cancel or reschedule your appointment.
NO SHOW POLICY
A ‘no show’ is an appointment that was not cancelled in advance (minimum of 48 hours). No shows inconvenience other patients who need dental care. A ‘no show’ for a scheduled appointment will result in a fee of $25.
LATE ARRIVALS
In an effort to serve our patients in a timely manner, we ask that you are on time for your scheduled appointment, please call the office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule.
Thank you for choosing Hometown Family Dental for your dental needs. We look forward to a long-lasting relationship with you.
ACKNOWLEDGEMENT
My e-signature below indicates that I have read, understand and agree to the appointment policy above.
WHY? Our goal is to provide quality dental care in a timely manner. In order to do so, we ask that patients adhere to our cancellation and no-show policy. The policy enables us to better utilize available appointments for our patients in need of dental care.
WHY? If you’re bringing your child to Hometown Family Dental, you must consent to dental treatment to him or her.
Many of our patients allow family members such as their spouse, parents or others to call and request dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.
Occasionally it is necessary for the staff of Hometown Family Dental to leave messages for patients. The purpose of these messages are to notify the patient that we would like to discuss treatment needs, billing purposes or to ask a patient to call back regarding an issue or concern. To expedite the receipt of the needed information, please indicate below if you would like to give consent to leave detailed messages. Please mark your preference below.
I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above authorized recipient or voicemail or email is no longer protected by federal or state law and may be subject to redisclosure by the above recipient or someone who has access to your voicemail or email. You have the right to revoke this consent in writing.
Have a quick question? Visit our FAQs. Otherwise, call us and set an appointment.
Location
1005 Lincoln St
Hobart, IN
Hours
M
T
W
Th
F – Sa
8a – 6p
9a – 4p
8a – 6p
9a – 2p
Appt only
Phone
(219) 942 4858
Location
1005 Lincoln St
Hobart, IN 46342
Hours
M
T
W
Th
F – Sa
8a – 6p
9a – 4p
8a – 6p
9a – 2p
Appt only
