MISSION DENTAL Primary Health Solutions - Mobile Dental Program Dear Parent or Guardian of the Hamilton City Schools: We are excited to announce that Primary Health Solutions – Mission Dental will again be partnering with the Hamilton City Schools to provide comprehensive dental care to the students of the Hamilton City School District. PHS-Mission Dental is a RETURNING PROGRAM being offered this year and is available to all interested students! PLEASE NOTE WITH YOUR PERMISSION PHS-MISSION DENTAL WILL BECOME YOUR CHILD’S DENTIST OF RECORD, WE WILL PROCEED TO SEE YOUR CHILD FOR ROUNTINE, EMERGENT, AND FOLLOW UP CARE INCLUDING SIX MONTH CHECK UPS. IF YOUR CHILD HAS A CURRENT DENTIST OF RECORD IT IS RECOMMENDED THAT YOU STAY WITH THAT PROVIDER TO NOT HINDER THAT RELATIONSHIP OR AFFECT YOUR INSURANCE BENEFITS. Primary Health Solutions provides the following dental services Dental Exams Cleaning X-Rays Sealants Restorations/Fillings Extractions Stainless Steel Crowns Dental Hygiene Instructions and Supplies Space Maintainers Treatment and services are provided on our mobile dental unit on the school premises each and every visit to ensure safety and security of your child. Initial Dental Exams/Screenings, X-Rays, Sealant, and Dental Hygiene Instructions Scheduled for:

PHS-Mission Dental accepts: All Medicaid plans, Private Insurance, Cash, Checks and Debit/Credit cards, as well as financial assistance for those without insurance. Our Staff will contact you to review your child’s treatment needs and answer any questions you have about your child’s dental health. **** VERY IMPORTANT - Parents/Guardians, if you would like to have your child participate in this program, please review and complete the attached paperwork and return to your child’s school by: If you should have any questions, please feel free to contact us at: Phone: 513-ϰϮϱͲϲϴϭϭ - Fax: 513-425-1810

1036 S. Verity Parkway

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Middletown, Ohio 45044

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Phone: 513-425-6811

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Fax 513-425-1810

Primary Health Solutions Mobile Dental Program Parental/Guardian Consent for Treatment of a Minor PATIENT NAME:

DATE OF BIRTH:

______

__

I, , do hereby give my consent to the dental staff of Primary Health Solutions to examine and treat the above named minor child. I understand there are certain hazards and risks connected with all forms of treatment and I give my consent knowing this. I authorize a staff member or volunteer from Hamilton City Schools to accompany my child onto the Dental Van. I understand that I will be notified by telephone before any dental decision or before any treatment. It is my responsibility to be available by telephone during the appointment for consultation. I understand that: 1. During the course of the visit any and all personal health information within the dental record of the child may be discussed in the presence of the Hamilton City Schools employee or volunteer. That is, if there is any information that may be in the child’s chart that you do not want them to know, you should not sign this consent. You need to bring the child in yourself. 2. If your child has a dental condition by history or exam that warrants a follow up appointment, it will be made for your child. The dentist may request that a parent/guardian be present at that follow up visit. 3. The dentist may decide not to perform procedures at the dentist’s discretion, for example if the dentist does not feel that there is not enough of a medical/dental history to provide the best care for your child. In signing this, I understand … 1. That I will be contacted to give permission for any procedures necessary for the dental care of my child and upon recommendation of the dental provider. 2. That I give my consent to the release of relevant health information to Primary Health Solutions in order to facilitate evaluation of my child’s dental needs. I further authorize Primary Health Solutions to release information regarding my child’s treatment to third party payors or others for purposes of billing, program management and evaluation in accordance with federal and state laws and regulations regarding confidentiality. I also give my permission to bill my insurance carrier or medical assistance for services received within the scope of this consent. For further details, see Primary Health Solutions Notice of Privacy Practices. 3. That Hamilton City Schools is in no way responsible for any dental treatment or the lack of treatment. The Hamilton City Schools is in no way a dental provider but only a link between families and dental services. Hamilton City Schools makes no representations or warranties, either express of implied, concerning the quality dental care provided by the dental care providers rendering services, examinations or treatment to your minor child. Name of Parent/Legal Guardian: ____________________________________________________________ Signature of Parent/Legal Guardian: __________________________________________________________ Date: Signature of Witness:______________________________________________________________________ SHOULD WE NEED TO CONTACT YOU REGARDING YOUR CHILD’S DENTAL CARE NEEDS DURING THE VISIT, WE WILL BE ABLE TO CONTACT YOU AT__________________________________________

Mobile Dental Program Consent Form 3-13

PRIMARY HEALTH SOLUTIONS PATIENT REGISTRATION FORM PATIENT INFORMATION: Last Name

First Name

MI

Nickname

Social Security #

Birth Date

Patient Billing Address (Responsible Party)

City

State

Zip

Patient Residence (if different)

City

State

Zip

Sex

RESPONSIBLE PARTY (Required for patients less than 18 and whenever the guarantor is not the patient): Last Name

First Name

MI

Social Security #

Birth Date

Relationship

INSURANCE INFORMATION (Please present ALL Insurance Cards and a Picture ID to the receptionist): Primary Insurance

Policy #

Group #

Effective

Co-Pay

Policy Holder

Relationship

Secondary Insurance

Policy #

Group #

Effective

Co-Pay

Policy Holder

Relationship

Tertiary Insurance

Policy #

Group #

Effective

Co-Pay

Policy Holder

Relationship

STATISTICS REQUIRED FOR GOVERNMENTAL REPORTING PRIMARY CARE AND PRIMARY DENTAL PROVIDERS: Please R Race: G White G Black/African-American G American Indian G Hawaiian G Pacific Island G More than one race G Other Please R Ethnicity: G Hispanic or Latino

G Not Hispanic or Latino

Please R to indicate the languages you can speak fluently: G English G Spanish G French G German Do you speak English fluently? G Yes Please R ALL that apply:

G Hindu

G Veteran

G Islamic

Please R Tax Filing Status:

G Russian

G Other: _____________________________

G Hearing Impaired G Smoker

G Christian

G Unknown/Not Reported

If no, preferred language: ___________________________________

G Visually Impaired

G Language Barrier Please R your Religion:

G No

G Agnostic

G Pentecostal G Return Not Filed

G Homeless G Atheist

G Scientologist G Single

G Divorced

G Single

G Life Partner

Please R Student Status:

G Married

G Migrant Farm Worker G Buddhist

G Widowed

G Jewish

G Other

G Married

If you R Head of Household, please indicate if the Head of Household is a: Please R Marital Status:

G Asian

G Male

G Head of Household G Female

G Legally Separated

G Other

G Full-time Student

G Part-time Student

CONTACT PREFERENCES: R to indicate the method of contacting preferred: G Home ( ) ______________ G Day/Work ( G Cell/Alternate ( ) ________________ G E-mail _____________________________________

) ______________

Emergency contact name and numbers ADVANCED DIRECTIVE: Do you have a living will? G Yes

G No

If YES, at which hospital is it filed? ________________________________

PRIMARY HEALTH SOLUTIONS, INC (PHS) Acknowledgement Of Receipt Of Privacy Practices We are required to give each patient a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. By signing this form you acknowledge receipt of this notice and a copy of our patient brochure. You may refuse to sign if you wish.

Please answer the following questions so that we can contact you in the most efficient way possible. If you have an answering machine at home, may we leave a message?

Yes

No

May we leave a message at your work for you to call our office?

Yes

No

May we e-mail you?

Yes

No

Is there a person at your house that we may leave a message with?

Yes

No

List below any person/persons authorized by you to discuss/receive your medical information: __________________________________________________________________________________ Name/address/phone/relationship __________________________________________________________________________________ Name/address/phone/relationship Employer (Name, Address, Phone Number

Do you live in public housing? G Yes

G No

Household Members Name

Date of Birth

Relationship

Income

Hr/Wk/Bi-Wk/Yr

Because we receive some funds to help us offer care to the uninsured, we are asked to keep track of the income of all our patients. We also offer a sliding fee scale for people with no insurance, and we need this information to calculate their discount. ALL INFORMATION WILL BE KEPT CONFIDENTIAL. Income Before Taxes $

Hr/Wk/Bi-Wk/Yr

Other Income

Documented

per

Family Size

I certify that all information given by me is true. I consent to any services rendered to me or my dependents by the attending provider/ physician. I understand this authorization will also permit the center to release information related to my medical records to other offices to assist in my continuing care. I acknowledge full financial responsibility for services rendered by Primary Health Solutions. I authorize the release of information to my insurance carrier and authorize payment directly to Primary Health Solutions. I have read and fully understand the above. Signature: _________________________________________________________ Date: ________________________________________ ( ) Patient

( ) Parent

( ) Guardian

Print Name and Address: ___________________________________________________________________________________________ Witness: ___________________________________________________________ Date: ________________________________________

Primary Health Solutions – Pediatric Dental History Date: _____________________________ Patients Name: _______________________________________________ Date of Birth: _______________________

Gender: _____________

Primary Emergency Contact Name: _______________________________

Contact Number: __________________

Other Emergency Contact Name: _________________________________

Contact Number: __________________

Patients Primary Care Provider (Name & Phone): ___________________________________________________________  Yes  No

If yes, when? __________________________________

Dentist Name: ______________________________________

Dentist Phone Number: __________________________

Has your child had a complete dental exam?

Has your child ever had any of the following (Check all that apply):  Kidney Disease  Rheumatic Fever  Liver Disease

 Anemia  Heart Problems  Speech Problems

 Diabetes  Hepatitis  Tuberculosis

 Asthma  Epilepsy  Hearing Problems

Are there any other medical concerns about your child’s health we should know about? ___________________________ __________________________________________________________________________________________________ Does your child have any allergies?  Yes  No If yes, please list all allergies, including medication, environmental or other. ____________________________________________________________________________________________ __________________________________________________________________________________________________ Is your child taking any medication now?  Yes  No If yes, please list all medications including, prescription and over-the-counter. ___________________________________________________________________________________ __________________________________________________________________________________________________ What concerns you most about your child’s dental health? ___________________________________________________ __________________________________________________________________________________________________ Does your child have any dental pain?

 Yes  No If yes, please describe: _________________________________

__________________________________________________________________________________________________ Has your child ever had a negative experience?

 Yes  No If yes, please describe: __________________________

__________________________________________________________________________________________________ How often does your child brush? _____________ Does your child floss?

 Yes  No How often? _____________

Has your child received fluoride treatments?  Yes  No If yes, when? ______________________________________ Has anyone explained the importance of primary teeth to your or your child? ____________________________________

I verify the above information and give my consent for treatment. Parent or Guardian Name: __________________________________

Date: _________________________

Parent or Guardian Signature: _________________________________________________________________