Please print and complete the office forms below prior to your child’s dental appointment. This will save you a little bit of time. There are 3 pages we would like you to fill out and bring with you: Parent & Insurance Info, Acknowledgement of Privacy Practices, and Financial Policy.
- /hub_sites/witte-john/www/assets/uploads/files/parent%20%26%20insurance%20info.pdf (Parent & Insurance Information)
- /hub_sites/witte-john/www/assets/uploads/files/ACKNOWLEDGMENT%20OF%20RECEIPT%20OF%20NOTICE%20OF%20PRIVACY%20PRACTICES.pdf (Acknowledgement of HIPPA )
- /hub_sites/witte-john/www/assets/uploads/files/financial%20policy.pdf (Financial Policy)
It is not necessary to bring the Notice of Privacy Practices Forms, just the Acknowledgement. But for your convenience, we have made it available to view the Notice of Privacy Practices Form below.
Please do not hesitate to call us if you have any questions.