My staff and I are delighted that you have chosen our office to care for your child’s dental needs.

Our mission is to care for your child with compassion and respect, promote sound teeth and a healthy lifestyle. We are proud to provide a relaxing, child friendly environment, specifically designed to engage your child. Our open door policy invites parents to accompany their children into the treatment areas. Our goal is for your child to have a positive dental experience. We offer a variety of treatment options to help alleviate an anxious child. These include: Nitrous oxide(or laughing gas),as well as general anesthesia in a comfortable, hospital type setting. Our friendly and expert staff is great with children, adding to the caring and nurturing atmosphere of our office.

We accept and file most insurance as a courtesy and convenience to you. Financing is also available with approved credit

We are happy to welcome your child as a new patient and hope to help him or her to maintain a beautiful, healthy smile for a lifetime.


Karen M. Sept, DMD
And Staff

Patient's Name:
Date Of Birth: / /
Patient Dental History
Please answer the following questions:
Describe child's brushing habits:
Is your child's water fluoridated?
Is your child taking fluoridesupplements?
Do your child's gums bleed while brushing or flossing?
Do you have any areas of concern?
Has your child had any injuries to his or her mouth, teeth, or head?
Has your child ever experienced clicking or pain of the jaw?
Does your child have frequent headaches?
Has your child had a negative experience with previous dental visits?
Is this your child's first visit to the dentist?
Other Comments?
Patient Dental History Continued
Please answer the following questions:
Does your child clench or grind his or her teeth?
Do you assist your child while flossing and brushing?
Does your child sleep with a bottle at night?
Does your child's bottle or sippy cup contain fluid other than milk or water?
Does your child suck his or her thumb and/or fingers?
Does your child enjoy chewing gum?
Has your child ever had dental X-rays?
Has your child ever had general anesthesia?
Has a family member ever had a problem with general anesthesia?
Patient's Name:
Date Of Birth: / /
Patient Medical History
Office Phone:
Routine Exams?
Is your child under medical treatment now?
Has your child been hospitalized for surgery or serious illness?
If yes, explain
Does your child have or has your child had any of the following?
Bleeding Disorder
Blood Trans.
Kidney/Liver Dis.
Heart Murmur
Heart Trouble
Respiratory Problems
Thyroid Problem
Hearing Impairment
Reactive Airway Disease
Tobacco/Drug Use
Hay Fever
Growth Prob.
Speech Prob.
Does your child have or has your child had any of the following?
Sleep Apnea
Cerebral Palsy
Is your child taking any medications(Including herbal and non-prescription medicines)?
If yes, list medications and dosages
If your child has asthma, when was his or her last episode?
Is your child allergic to any of the following? (Check all that apply)
Last Albuterol use:
Other Comments:
Authorization, Release, & Agreement to Pay for Services Rendered
  • I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me to third party payers and /or health practitioners.
  • I authorize and hereby request my insurance company to pay directly to the dentist (or the dental practice) insurance benefits that otherwise are payable to me.
  • I understand that my dental insurance carrier may pay less than the actual bill for services.
  • I agree to be responsible for all services rendered on my behalf or on behalf of my dependents.
  • I certify that i have read and understand the above information. To the best of my knowledge, the above answers have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health.
Date :
New Patient Information
Child's Name:
DOB: / /
Responsible Party Information
Home Phone
Cell Phone
Spouse Name
Cell Phone
Email Address
Mother’s Employer
Mother’s Social Security Number
- -
Mother’s DOB
/ /
Home Phone
Cell Phone
Spouse Name
Cell Phone
Email Address
Father’s Employer
Father’s Social Security Number
- -
Father’s DOB
/ /
Emergency Contact
Phone Number(s)
CHILD’S INSURANCE(Please document insurance coverage in addition to the following on the reverse of this form)
Dental Insurance Company that Covers the Child
Subscriber’s Name
Date of Birth
/ /
Group Number
ID Number
Has any other immediate family member been treated in this office?
How did you hear about our practice?

I authorize my insurance benefits to be paid to Dr. Karen Sept. I also authorize Dr. Karen Sept to release any information required for all insurance claims.

I acknowledge that I am financially responsible for all charges whether or not they are paid by insurance. If I desire credit to be extended to me and/or my family for services rendered, I am aware that a credit report may be obtained before credit is extended.

/ /
Additional Insurance Coverage
Secondary Insurance
Dental Insurance Company that Covers the Child
Subscriber’s Name
Date of Birth
/ /
Group Number
ID Number
Tertiary Insurance
Dental Insurance Company that Covers the Child
Subscriber’s Name
Date of Birth
/ /
Group Number
ID Number
Phone Number of Insurance Company
Child’s ID Number If Different From Subscriber
Child's Medical Insurance Infomation.
Name of medical insurance company
Subscriber's Name
Group Number
ID Number
Phone number of insurance company
Child’s ID number if different from subscriber

Notice of Privacy Practices

This notice describes how medical information about your child may be used and disclosed, and how you can get access to this information. We are required by law to provide you with this notice of our privacy practices. PLEASE REVIEW IT CAREFULLY.
Palouse Pediatric Dentistry (PPD) maintains a record of the dental services we provide to your child.This includes symptoms, our findings, test results, diagnoses, and treatment provided, as well as health information from other providers and billing and payment information related to these services. Federal and state laws allow us to use this information to provide care for your child while also requiring us to protect the privacy of their information.
We respect you and your child's privacy.We understand that your child's personal health information is very sensitive.
We will never disclose you or your child’s health information to others unless you tell us to do so, or the law authorizes or requires us to do so.

How Your Child's Health Information is Used

I. For Treatment:
  • - Information will be used to help decide what care may be right for your child.
  • - This information may be shared with other health care providers who are caring for your child.
I. For Payment:
  • - Diagnoses, procedures performed, or recommended care may be provided to your dental insurance plan so that we may receive payment from them.
  • - You may opt to restrict the disclosure of your child's personal health information to your dental insurance company/companies. We will gladly respect your wishes in this regard:
    However, this will require that you pay entirely out-of-pocket at the time of service
I. For Health-Care Operations:
  • - Information may be used to assess and improve the quality of care we provide
  • - We may contact you to remind you about upcoming appointments.
  • - Information may be used to conduct or arrange for services, including:
    • - Quality review by your health plan
    • - Accounting, legal, risk management, and insurance services
    • - Audit functions, including fraud and abuse detection and compliance programs
Child's Name
Date of Birth / /

Office and Financial Policies

Payment is due at the time of treatment. We accept cash, check, debit cards and major credit cards. We also offer a flexible payment plan, Care Credit, which may allow you to start your treatment today and spread payments out over time. Applying for Care Credit takes only a few minutes and there is no fee to apply.
It is your responsibility to know your insurance coverage and provide us with the most current insurance information. Remember that your insurance is a contract between you and your insurance company and we are not a party to this agreement. We will process most patients' insurance, and are in network with Delta Dental, Blue Cross of ldaho, Cigna Radius and Dental Health Alliance (DHA).
As a courtesy, we will submit insurance claims for you. We will assist you in estimating your portion of the cost of service, but we cannot guarantee how your insurance company will handle each claim or for what benefits they pay on a given claim. Please note that insurance companies generally only pay a portion of the bill, and you are responsible for the payment of any and all remaining balances after insurance payment.
Any account delinquent in excess of 90 days will be turned over a third party collection agency.
It is possible that some or all of your treatment may not be covered by your insurance provider or not considered reasonable and customary according to their terms.The responsibility of payment for your child's dental care is yours. If your insurance company has not paid the assignment of benefits that we have accepted within 60 days, we will transfer these unpaid claims to your account for payment. Payment in full is required upon notification.
There is a $35.00 fee for all returned checks.
Our office requires at least 24 hours notice to cancel an appointment Missing an appointment or canceling fewer than 24 hours prior to a scheduled appointment may result in a $50.00 fee. Two missed appointments may be grounds for dismissal from our practice.
Please arrive on time for your appointments. If you arrive late to an appointment, we may not be able to see you that day and may need to reschedule your appointment. Repeated tardiness and rescheduling may result in a missed appointment fee of $50.00.
A parent or legal guardian must always accompany the child to his or her appointments.
By initiating above and signing below, I acknowledge that I have read and agree to accept the terms of this policy statement:
/ /
This signature will apply for all insurance claims.

Consent for Use and Disclosure of Health Information

Patient's Name
Date of Birth
/ /
Patient's Name
Date of Birth
/ /
Patient's Name
Date of Birth
/ /
Patient's Name
Date of Birth
/ /
To the patient's representative:
By signing this form, you will consent to our use and disclosure of your child's protected health information to carry out treatment, payment activities, and healthcare operations.
A copy of notice of our Notice of Privacy Practices accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
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.
You may obtain a copy of our Notice of Privacy Practices, including any revision of our Notice, at any time by contacting Michele Walker, Privacy Administrator for Karen M. Sept, DMD, Palouse Pediatric Dentistry, LLC. Phone 208-882-9999 or Fax 208-882-9998.
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to Michele Walker. 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 your child or to continue treating your child if you revoke this Consent.
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 child's protected health information to carry out treatment, payment activities and health care operations.
/ /
Print Name
Relationship to Patient

You are entitled to a copy of this consent after you sign it.

Your Health Information Rights

The health and billing records we create and store are the property of PPD. The protected health information in it, however, generally belongs to you.
You have a right to:
  • - Receive, read and ask questions about this Notice, as well as obtain a copy of this notice for your records.
  • - See and obtain a copy of your child's protected health information. You may request that this information; be provided to you in written or electronic format. Please make this request in writing.
  • - Ask us to change your child's health information. Please make this request in writing.
  • - Receive a list of disclosures of your child's health information(excluding disclosures to third-party payers)
  • - Cancel prior authorizations to use or disclose health information. Again, please provide this request in writing.
  • - Ask us to restrict certain uses and disclosures of your child's health information. You must deliver such a request in writing to us. Though we are not required to grant your request, if we are able and do grant it, we will comply with your wishes.

Our Responsibilities

We are required to:
  • - Keep your child's protected health information private
  • - Give you this notice
  • - Follow the terms laid out in this notice.
We may change our practices regarding the protected health information we maintain. If we make changes, we will update this notice. You may receive the most recent copy of this notice by calling and asking for it or by visiting our office to pick one up.

To Ask for Help or Make a Complaint

If you have questions, want more information, or want to report a problem about the handling of your child's protected health information, you may contact the Practice Administrator during regular business hours. You may also deliver a written complaint to practice Administrator. You may also file a complaint with the U.S. Secretary of Health and Human Services. If you file a complaint, we will not retaliate against you in any way.

Other Disclosures and Uses of Protected Health Information

I. Notification to Family and Others
  • - We will only release your child's health information directly to a legal guardian
  • - We may also give information to someone who helps pay for your child's care.
  • - We may release health information about your child to a friend or family member, but only at your request or with your approval.
  • - In the unlikely event of an emergency where it is necessary for us to inform your family of your child's location and general well being. The person contacted will be, if at all possible, the individual you designate to contact in case of emergency.
If you are not comfortable with and do not agree with any of these policies and practices regarding your child's health information privacy, please inform us and we will do our best to follow your wishes.
II. Other situations where your child's health information may be used without your authorization.
  • - To an Outpatient Facility: Relating to provision of anesthesia services for surgical procedures.
  • - To the Food and Drug Administration: Relating to problems with regulated products.
  • - To Comply with Workers' Compensation Laws Relating to problems with regulated products.
  • - To Public Health and Safety Purposes as Allowed or Required by Law, to prevent or reduce a serious threat to the health or safety of a person or the general public.
  • - To Report Suspected Abuse or Neglect to public authorities.
  • - For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you or your child are victims of a crime.
  • - For Health and Safety Oversight Activities For example, we may share health information with the Department of Health.
  • - For Work-Related Conditions that Could Affect Employee Health For example, an employer may ask us to assess health risks on a job site.
  • - To the Military Authorities of U.S. and Foreign Military Personnel if your or another parent/guardian are enlisted.
  • - In the Course of Judicial/Administrative Proceedings at your request , or as directed by subpoena or court order.
  • - For Specialized Government Functions. For example, we may share information for national security purposes.
  • - In the event of the patient's death we may disclose relevant protected healthcare information of the deceased patient to a family member, friend, or representative, if that family member, friend, or person had been involved in the patient's care or payment before death, unless disclosure would be inconsistent with the patient's express wishes to the practice.
III. Other Uses and Disclosures of Protected Health Information will be made only as allowed or required by law or with your written authorization. This includes, but is not limited to:
  • - The transfer of your child's records to a doctor who did not refer you to PPD, or you were not referred to by PPD. For example, if you move from the area, and see a new doctor, a signed release is required in order for PPD to release your records to that doctor.
  • - The transfer of your child's records in the course of judicial/administrative proceedings at your request or as directed by a subpoena or court order
Should there be a security breach that potentially affects patient privacy and protected health information, we are required to:
  • - Notify Patients
  • - Take steps to mitigate the damage
  • - Notify the Department of Health and Human Services (HHS)
We have a web site that provides information about us. For your benefit, this notice is on the website at this address: http://www.palousepediatricdentistry.com/office.htm

This Notice Effective 13 March 2014