IMPORTANT NOTICE & CONSENT / AVISO IMPORTANTE Y CONSENTIMIENTO 

I understand and authorize OHIP Lawrence B. Caplin DMD, P.A.(Provider) (Provider) and its affiliated dentists or dental hygienists to provide the following services for the named child for whom I am the
custodial parent or legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants, as well as the application of Silver Diamine Fluoride to treat the
progression of tooth decay. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color.) I also authorize the dentist to fill any cavities or to place a crown over the tooth,
extract any problem baby teeth, perform a pulpotomy (treatment of the nerves inside the tooth), place space maintainers or perform other dental treatments as needed. I understand that there are risks
to dental treatment including swelling or pain that may occur from the treatment or injection of a local anesthetic, or allergic reaction. (For additional information regarding the risks of treatment and
treatment alternatives, please call the number provided.) I authorize & direct Provider to bill & collect payment from any Medicaid, insurance, or other payer. I authorize my child’s school to make available
to Provider and its billing agent my child’s insurance information in order to bill payer for services. If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co pays.
Treatment by the in-school dentist may affect future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at the
time of service, services will be provided without my presence. (We may send you text messages about the school dental program. Message and/or data fees may be charged by your wireless service
provider; to discontinue, reply “STOP” to any message received from us. You also agree to receive pre-recorded and/or auto-dialed telephone calls relating to the school dental program at the land-line
and/or mobile telephone numbers provided on this consent form.) I have received the Notice of Privacy Practices (NPP) attached to this form and consent to the release of my child’s medical record
information, including records obtained from other providers, and any HIV/AIDS, communicable disease, sexually transmitted disease, drug and alcohol, and anemia information. I authorize release of
such information by Provider to any responsible payor and/or administrative service provider and their subcontractors, and if my child is a participant in the Maryland Healthy Smiles program, the primary
dentist office with which the Provider contracts for my child’s school, for use and disclosure relating to my child’s treatment, payment for services and health care operation purposes. This signed consent
authorizes my child’s initial and future dental visits. By signing this consent form, I agree to allow my child to receive dental services, and agree to waive any and all claims or liability associated with these
services against the officers, directors, employees, agents, affiliates of OHIP Lawrence B. Caplin DMD, P.A. and related dental staff, the Student Health Impact Project (SHIP), and the Prince George’s
County Public Schools (PGCPS). My signature shows that I have read and understand the terms of the dental consent form and I agree to its provisions. Following the Health Insurance
Portability and Accountability Act (HIPAA) rules, I authorize Prince George’s County Public Schools (PGCPS) to share my child’s Personal Health Information (PHI) with OHIP Lawrence B. Caplin DMD,
P.A. and dental staff for the purpose of treatment of my child’s oral health condition and maintaining the continuity of my child’s care. I understand that The Notice of Privacy Practices document was
provided to me and available to me on the Oral Health Impact Project’s website. This permission is valid from the date of signature until my student is no longer a City Schools student, unless I withdraw consent in writing. I may withdraw this consent at any time in writing.

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Entiendo y autorizo a OHIP Lawrence B. Caplin DMD, P.A. (Proveedor) y a sus dentistas afiliados o higienistas dental a proveer los siguientes servicios al niño mencionado del cual soy el padre
custodio o tutor legal: examen dental e instrucciones de higiene oral, limpieza dental, tratamiento de fluoruro, rayos-x, sellantes dentales, así como la aplicación de Fluoruro Diamino de Plata para tratar
la progresión de las caries dental. (El uso de Fluoruro Diamino de Plata puede decolorar cualquier caries a un color marrón o negro.) También autorizo al dentista a llenar cualquier carie o colocar una
corona sobre el diente, extraer cualquier dientes de leche problemáticos, realizar una endodoncia (tratamiento de los nervios dentro del diente), colocar mantenedores de espacio o realizar otros
tratamientos dentales según sea necesario. Autorizo al Proveedor a extraer cualquier diente de leche con problema o realizar una endodoncia (tratamiento de los nervios dentro del diente), como sea
necesario. Entiendo que existen riesgos al recibir tratamientos dentales incluyendo inflamación o dolor que puede ocurrir de la inyección de la anestesia o una reacción alérgica. (Para información
adicional sobre los riesgos del tratamiento dental y tratamientos alternos por favor llame al número proporcionada.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado o
tercera persona. Autorizo a la escuela de mi hijo a poner a disposición del Proveedor y su agente de cobro la información del seguro de mi hijo con el fin de cobrar por los servicios. Si tengo seguro dental
privado, seré facturado y acuerdo a pagar cualquier deducible y/o co-pago. El tratamiento realizado por el dentista escolar pudiera afectar los beneficios de su niño en en un futuro bajo su cobertura
privada, Medicaid o CHIP. Al menos de que allá hecho algún arreglo previamente para atender y estoy ahí al momento de los servicios, el servicio será proveído sin mi presencia. (En ocasiones
podremos mandarle un texto sobre el programa dental escolar. Cobros de mensaje o/y de datos pueden ser aplicados por su proveedor de servicios inalámbrico; para descontinuar, responda “STOP” a
cualquier mensaje que reciba de nosotros. Usted también acepta recibir transmisión pre grabada y/o auto llamadas telefonicas relacionadas con el programa dental escolar a los numeros telefonicos que usted proporciono en esta forma de consentimiento.) He recibido el Aviso de Prácticas Privadas (NPP) adjuntas a este formulario y el consentimiento para la divulgación de la información y/o expediente
médico de mi hijo, incluyendo los registros obtenidos de otros proveedores, y cualquier otra enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisión sexual, drogas, alcohol, y anemia. Autorizo la divulgación de dicha información por parte del Proveedor a cualquier pagador responsable y/o proveedor de servicios administrativos y sus subcontratistas, y si mi hijo participa en
el programa Maryland Healthy Smiles, la oficina del dentista principal con el que el Proveedor contrata para la escuela de mi hijo, para uso y divulgación relacionados con el tratamiento de mi hijo, el pago
de servicios y propósitos de la operación de cuidado de la salud. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Este permiso es válido desde la fecha de
la firma hasta que mi estudiante ya no sea un estudiante de City Schools, al menos que retire mi consentimiento por escrito. Puedo retirar mi consentimiento en cualquier momento por escrito.

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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, 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 not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services.


Contact Officer: HIPAA Officer
Phone: 866-916-6447
Fax: 844-751-0258

 

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Your child's school has joined the
Oral Health Impact Project
to offer in-school Dental Care at
NO COST* to you.


Review the OHIP Maryland, P.C Privacy Policy

Taking care of your child’s teeth is important to keep them healthy.

EASY & CONVENIENT - A state licensed dentist will regularly check your child’s mouth & teeth, as well as provide a cleaning, x-rays as
necessary, fluoride treatment and apply sealants, as needed. Additional care, such as fillings, may also be provided. A dental report card will
be sent home with your child. Includes initial dental care & follow-up visits. SIGN AND RETURN TO YOUR SCHOOL TODAY!

Date Signed: November 27, 2021

Please select who will be enrolling
Minor
Continue
First Child's Name

First Name*

Middle Name

Last Name*

Phone*
First Child's Date of Birth*
First Child's Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Insurance

Insurance Carrier*

Insurance Policy Number*
SCHOOL INFORMATION

What school does your child attend? *

What grade is your child in?

What is your teacher's name?
IMPORTANT HEALTH QUESTION

Does your child have any past or present medical or dental conditions or disabilities? This may include heart issues, breathing problems, brain/seizure disorders, allergies (including drug allergies), diabetes, bleeding problems, communicable diseases or immune disorders etc. If Yes, explain below (attach additional pages as needed). IF NO, LEAVE BLANK.

List any dental concerns

List current medications
READ & SIGN BELOW

I understand and authorize OHIP Lawrence B. Caplin DMD, P.A. (Provider), its affiliated dentists or dental hygienists, to provide dental services at school to the above named child for whom I am the custodial parent or legal guardian, including an exam, cleaning, fluoride, sealants, fillings, x-rays and the application of Silver Diamine Fluoride as needed. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color). If additional services like extractions of baby or adult teeth, or pulpotomy are needed for my child, I must agree to those services before they are provided. This permission is valid from the date of signature until my student is no longer a Prince George's County Public School student, unless I withdraw consent in writing. I have read the IMPORTANT HEALTH QUESTION above and will report any significant changes in my child's health to (866) 916-6447 for OHIP. I have read the IMPORTANT NOTICE AND CONSENT ON THIS FORM and understand and agree to its terms.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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