For your convenience, you may download and print necessary office forms. We ask that all of these forms be completed in advance and brought to your first visit. This will allow your child to be seen on time as scheduled. All forms are .pdf documents. Just Call (843) 556-1655 and schedule your kids an appointment with our dentist in Charleston, SC.
Medical History Form
Acknowledgement of Receipt of Notice of Privacy Practice
Authorization to Release Healthcare Information
CCD Permission Letter
Sedation Reservation Fee
SCDA Action Alert Important Information Regarding Section 1557
By now you have most likely heard of Section 1557 of the Affordable Care Act (ACA) that was designed to protect individuals from discrimination in health care. The Office of Civil Rights (OCR), which currently enforces HIPAA, will be enforcing Section 1557 as well.
Dentists and dental practices that receive certain payment from the U.S. Department of Health and Human Services, such as Medicaid or CHIP reimbursement or “meaningful use” payments under the Medicare and Medicaid Electronic Health Records Incentive Program must comply with Section 1557. Additionally, the final rule applies to a dental practice that receives reimbursement under Medicare Advantage (Medicare Part C), whether the plan reimburses the dentist or the patient.
These practices must have certain notices displayed in their practices and on their websites by October 16, 2016. They must be included within certain publications as well.
There are 2 notices to display and below are links to those notices. One is for practices who employ less than 15 employees and the other is for larger practices. The larger practices must assign a team member as the grievance coordinator and have a grievance procedure in place, therefore their notice differs from that of a smaller practice. These forms are electronically writable, but you must first be sure to download them to your computer.
Regardless of size, all practices impacted by Section 1557 will utilize the below “ADA Taglines” as the second notice and it contains the 15 most commonly used languages in our state.
The final link contains a list of translators that you may utilize should you so choose. These companies are not endorsed and/or sponsored by the SCDA in any manner. This list is provided as a simple reference only.
Below is a link to the ADA’s Centers for Professional Success and it has a wealth of information regarding Section 1557 of the ACA. This is a member benefit, so you must log in with your ADA number in order to fully view this link.