Download So, what`s inside? - Wentzville R

OCTOBER 2015 | VOLUME IV | ISSUE 2
ART CLUB ENCOURAGES PEACE
So, what’s inside?
On September 21, Art club
"planted" 800 pinwheels
for International Day of
Peace. Students, families,
and community groups
worked together to create
the pinwheels that Art
Club assembled and
installed on Perry Cate
from Timberland to South
Middle School. This project is meant to be a public statement and art
installation for the spinning pinwheels to spread thoughts and feelings about
peace throughout our school and community. Today, society is bombarded
with images and stories that give importance to conflict and war. Violence
has become commonplace and accepted as part of our society and, for
some of us, it is a way of life. It is Art Club’s hope that through the Pinwheels
for Peace project, they can help make a public visual statement about their
feelings about war, peace, tolerance, cooperation, harmony, unity and, in
some way, awaken the public and let them know what the next generation
is thinking. This is not political. Peace isn’t just conflict of war, it can be
related to violence and intolerance in our daily lives, to peace of mind. To
each of us, peace can take on a different meaning, but, in the end, it all
comes down to a simple definition: a state of calm and serenity, with no
anxiety, the absence of violence, freedom from conflict or disagreement
among people or groups of people. Hopefully, this project helped everyone
that participated and drove by find peace and have a chance to share it
with others.
Upcoming Events ................ 02
Next year, they have a goal of planting 1,400 pinwheels to
travel from Timberland all the way to Highway N. If you
would like to participate, click here to get the template for
the pinwheel. Cut out the pinwheel square. On the back,
write thoughts about war and peace, tolerance, and living
in harmony with others. The writing can be poetry, prose,
haiku, or essay. On the front, draw something that
represents peace. You don’t have to be a great artist to
try this—just be free and expressive with colors or lines by
doodling. Mail or deliver to Timberland High School Art
Club, and they’ll assemble them and install them next year
on September 21, International Day of Peace. “First keep
peace with yourself, then you can also bring peace to
others.” Thomas Kempis
Timberland Times Newsletter designed by Megan Spotila
Early Graduation ................. 02
ACT Dates ................................ 02
After-School Tutoring ........ 02
Principal’s Note .................... 03
PSAT/NQMST ........................... 03
A+ Training ............................... 04
Lewis and Clark .................... 04
Sophomore Meeting ......... 04
Parent Teacher Conf. ....... 04
College Fair............................. 05
Greenhouse ............................ 05
Driving Lessons ...................... 05
Free Dental Care ................ 06
STL Teen Idea Dash ............ 07
Senior Ad .................................. 07
Yearbook .................................. 07
Design Field Trip ................... 08
DECA Den ................................ 08
Glow Run/Walk..................... 09
Oktoberfest ............................. 09
THS
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
UPCOMING
EVENTS
SENIORS: EARLY GRADUATION
Seniors interested in graduating at semester
must fill out a notification form. Students may
stop by the Guidance Office before or after
school or during lunch to pick up the form.
Completed forms with parent signature must be
returned no later than Friday, November 6 to
the Guidance Office.
OCTOBER
05
Late Start, Grades 6-12
05
Fall Choir Showcase
08
A+ Training
10
NHS Glow Run @6pm
14
First Quarter Ends
15
NHS Meeting @6:30am
16
Early Release
19
Late Start, Grades 6-12
24
ACT Testing
28
Parent Teacher Conferences
AFTER-SCHOOL TUTORING
@3:30-7pm
30
NO SCHOOL
NOVEMBER
02
PD Day– No School
06
Early Graduation Forms Due
Timberland offers tutoring sessions for all students Monday
through Thursday from 2:25 to 3:25 in the library. Teachers
supervise students until they are ready to leave the
building.
If your student is riding home on the Activity Bus, he or she
must remain with the teacher until 3:20. To ride the Activity
Bus, your student must sign up the day he or she plans to
stay after. Activity bus sign-ups are in the main office with
Mrs. Swofford. Your student is allowed to sign up before
school, between classes, and during lunch.
There is NO ACTIVITY BUS ON FRIDAYS.
Please check the school webpage for the official after
school tutoring schedule.
ACT TEST DATES
2015 | October 24
December 12
2016 | February 6
April 9
June 11
To sign up for
the ACT, click
here.
ACT WORKSHOPS
Science | 10.1 & 10.8
Math | 10.13 & 10.15
English | 10.20 & 10.22
All workshops are 7:00-9:00 pm.
Students are asked to sign up in
the guidance office.
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 2
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
FROM MR. LINDQUIST’S DESK...
Another fall is upon us, and the first quarter is quickly drawing to a close. If you
have not yet had a chance to do so, please access the parent portal to check
on your son or daughter’s grades so there are no surprises when the quarter ends.
In addition, many of our teachers have their assignments and other materials on
Moodle or Google classroom. Your son or daughter can log on to show you what
is going on in their classes.
With one quarter almost in the books, I want to take a moment to talk about
attendance and a change for this year. In the past, only students with
attendance concerns were notified by the school. This year we will be
communicating with all students about their attendance after the first quarter
ends. While it is important to communicate with students who are developing
concerns, we also feel it is important to acknowledge those students who are
meeting or exceeding expectations. Once you receive that information we ask
that you talk with your child to either congratulate him or her on good attendance or to discuss how things can
improve if needed.
Many research studies have shown attendance to be one of the top indicators for success in school. In addition
we want students to build good habits that will serve them well after high school and throughout their lives. We will
not ask anyone to send a sick child to school, but do ask that your child make every effort to be here otherwise.
Thank you for your support on this.
On another note, we have lots of opportunities for parents and families to join us this fall. We will have parent/
teacher conferences on October 28th from 3:30-7, a fall choir showcase on October 5th, the Bands of America St.
Louis Super Regional at the Edward Jones Dome on October 16-17, and the fall production of Three One Acts on
November 12-14, just to name a few. That doesn’t even include all of our sports and other competitions. We love
to see involved parents. We hope we will see you at one of our events.
Thanks for all you do. Go Wolves!
PSAT/NMSQT TESTING
Your sophomore or junior student will have the option to take the PSAT/NMSQT
(Preliminary Scholastic Aptitude Test/National Merit Scholarship Qualifying Test) on
Wednesday, October 14.
Juniors who wish to prepare for a future SAT test and/or wish to participate in nationwide
scholarship competitions administered by the National Merit Scholarship Corporation are
good candidates. Sophomores are also allowed to take the test, especially if they intend to
take it again as juniors as only juniors may compete for scholarships.
The fee to take the test is $15.00 per student, due at registration. Please make checks
payable to Timberland High School—NO CASH WILL BE ACCEPTED. Register in the
Guidance Office until October 10, seating is limited.
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 3
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
A+ TRAINING INFO
The next A+ training session is Thursday,
October 8 in room 163 from 2:30 pm to 3:30
pm. This training is open to juniors and
seniors. Students must pre-register in the
Guidance office. Students must attend one
training session before they begin tutoring.
All seniors must complete training by
December in order to ensure time to
complete the tutoring by May 1st. For more
information, refer to the Career Center
Website.
2015-2016 Training Dates
October 8 | Grades 11-12
November 5 | Grades 10-12
December 3 | Grades 10-12
January 7 | Grades 10-11
February 4 | Grades 10-11
LEWIS & CLARK
CAREER CENTER
Representatives from Lewis and
Clark visited with interested
Timberland sophomores on
September 30 to share details
about the programs offered and
the application process. The
application process is competitive
and applications are due by
Tuesday, November 24.
On November 12, Lewis & Clark will
be hosting a Prospective Student
Night at the facility, which is
located at 2400 Zumbehl Rd in
Saint Charles, MO.
March 3 | Grades 10-11
April 7 | Grades 10-11
May 12 | Grades 10-11
ATTENTION SOPHOMORE PARENTS:
The Guidance counselors visited your child's
classroom recently sharing events pertinent to the
10th grade year. Highlights of this presentation
were emailed to you in late September. In brief,
the counselors presented information about the
PSAT exam, and the Lewis and Clark Career
Center, details of which you will also find in this
newsletter. Students were encouraged to visit the
College / Career / A+ website from the
Timberland home page; and they
were reminded of the process to request an
appointment with their counselor.
PARENT/TEACHER
CONFERENCES
Timberland High School
Gym and Cafeteria
October 28
3:30 to 7:00 pm
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 4
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
Art club and Ecology club are in the process of building a greenhouse out of
recycled materials and material purchased using a mini grant that was awarded last year.
Recycling collected from around the school and many recycled slushy flavoring bottles,
supplied by DECA, have been used for the structure. It has yet to be finished, but the walls are
nearly complete. When it is complete, the goal is to use it for growing plants for different
classes in the science department, as well as growing produce that FACS could utilize in
cooking classes. Art classes could also utilize the space for growing flowers that could be used
as subjects in drawing, painting, or photography classes.
If you would like to help out with the project contact David Spak or Crystal Wing.
Thinking College?
St. Louis National College Fair
Sunday, October 18
1pm-4pm
DID YOU KNOW THS OFFERS
DRIVING LESSONS?
Any THS student who is between the ages of
15 and 18 can sign up for 6 hours of instruction
in driving for $200. Students do not have to be
enrolled in the Driver’s Education course to
sign up for the lessons. Check with your
insurance company as you may be eligible for
a discount on your insurance rates. Students
can sign up anytime before May 15 in Room
219. If you have questions, please contact Bill
Located at St. Louis University in the
Simon Recreation Center
Register online by following these steps:
1. Go to the www.gotocollegefairs.com website
2. Click on the “Student Register Now” button
3. Select the state (MO), choose the fairs you will
attend. (2015 Fall MOACAC Fair Listings)
4. Complete the registration form once
5. Submit the form. The barcode is displayed.
6. Print and take to fair.
Schoonover.
For the most up-to-date news at Timberland check out our website!
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 5
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
From the Nurse’s Office: Dental Care
Your child can receive state-of-the-art dental services from a Missouri licensed dentist while at school!
Timberland is proudly hosting the "SMILES PROGRAM" dental clinic on
Wednesday, October 28th, 2015 for Medicaid or privately insured students.
The Smiles Program, started over 17 years ago, features local, caring, Missouri licensed dentists and hygienists who
come into the schools and provide exams, cleanings, x-rays, flouride, sealants and even fillings. Also, the students
will be taught how to care for their teeth and the dangers of tobacco products. For those students without
Medicaid or private insurance and lacking sufficient funds, the mobile dentists provide generous grant-assistance.
NO CHILD IS EVER TURNED AWAY for lack of resources.
For your child to participate, please print and fill out the parent permission form on page 12, or permission slips can
be picked up in the THS school nurse's office anytime Monday-Friday between 6:45am-3:15pm.
PERMISSION SLIPS NEED TO BE RETURNED TO THE SCHOOL NURSE BY WEDNESDAY, OCTOBER 14, 2015.
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 6
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
Congratulations to Lexie Maitland who was chosen to
represent Prosper Youth & Collegiate at Saint Louis University's STL
Teen Idea Dash. This is a very selective event where various schools
and community organizations are asked to send their "best of the
best”!
The Teen Idea Dash is a scavenger hunt style competition in which
teens must tackle various innovation challenges, generate unique
solutions to designated problems, and decipher clues as they race
throughout the City Museum on October 3. Competitors will present
their ideas to judges at various points along the course. Once all
teams have arrived at the final destination, teams will receive a
final score based on their finish line placing as well as the quality of
their ideas.
The winners of this event will join members of Independent Youth's
Teen Network (who will be flying in from all around the country)
AND the finalists for SLU's College-Level Pure Idea Generator
Challenge (nationwide) for a great evening of activities including a
Gateway Riverboat Cruise, a VIP tour of Busch stadium, and dinner
by some of St. Louis favorites. This is a fantastic opportunity for
aspiring young entrepreneurs to meet and network with these rock
star teens and college students who have had great success at a
young age.
ATTENTION SENIOR
PARENTS:
Would you like to honor all
your child has
accomplished during their
years at THS? Would you like
to capture the memories of
a lifetime in a keepsake that
can be kept forever? Buy a
SENIOR AD for the
yearbook. Please see
page 10 for a 2015-16 Senior
Ad order form.
YEARBOOKS
Order ONLINE or CALL
1.866.287.3096, the school code is
8123
Credit, Debit, and Checks only!
Before Dec. 22, yearbooks are $55.
After Dec. 22, yearbooks are $60.
Nameplates are available for an
additional $5.
Also, seniors need to get their pictures taken and chosen- by Trotter by Dec. 11. This means
they need to take them by Dec. 1 if they
want to choose the pose online.
Questions? Contact Ida Hoffman at:
Idahoffmann@wsdr4.org
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 7
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
Wolves in the Community...
The Housing and Interior Design class recently went on a field trip to the Campbell House and
the Hanley House, two very historic homes in the St. Louis area. Students were able to see
how people lived in the 1880's in St. Louis. After touring the Campbell House, students and
teachers did some service work around the gardens.
The DECA Den
at Timberland High School is
open for business. The new
layout as well as the new blue
and green paint colors help to
give the store a more
welcoming vibe for all
customers.
The DECA Den sells slushies, popcorn, fruit snacks, granola bars,
Gatorade, t-shirts, and Smoothie King every Friday. The store
has developed a new system of designing, creating, and
delivering specially designed t-shirts to those who order them
as well.
The DECA Den has also started a new slushies reward system.
Each customer is given a punch card and after they buy nine
slushies, they get the tenth one free. DECA has been working
hard and is excited for to see how the store does this year!
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 8
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
Click here or visit the THS website for registration information!
St. Charles Oktoberfest
Timberland High School Art Club was excited to be a part of the St. Charles County Oktoberfest again
this year. Through the last eight years, Art Club and the Timberland Art Department has painted all of
the decorations in the Children's area, the grand entrance to the festival along with numerous cutouts for festival goers to take pictures, and sculpted the massive pumpkin sculptures every year. We've
constructed a serpent, alien ship, Mr. Potato Head, weiner dog, giraffe and a lion, tiger and bear. This
year we made a life-size horse sculpture based on the Clydesdale. Current students, alumni and
parents help in this sculpting event, which is led by art teacher, Crystal Wing. We had alumni from the
first year Timberland opened through last year's graduates. Special recognition should go to Tristin
Davis, and his Uncle Ron Ormsby for welding the frame. This project was the idea of Dan Foust with the
Lion's Club, and he is responsible for allowing us this great opportunity!
Timberland Times Newsletter designed by Advanced Business Technology Class
PAGE 9
•
*• *
Congratulate your senior and express your pride and love with an ad in the 2015 yearbook!
YEARBOOK
YEARBOOK
YEARBOOK
YEARBOOK
1/8 page:
$ 75
1/4 page:Details:
$100
Message
Congratulations Sara!
You have had such an amazing year! We are so proud of all of
your accomplishments. You really have turned out to be such
an amazing young woman and we couldn’t be happier for you.
We know you have a wonderful future ahead of you and can’t
wait to see what you accomplish!
Love, Mom, Dad, Johnny and Fluffy
1/4 page ad:
approximately 4”x 5 1/2”
1/2page:
page: $ $175
1/8
75
50
1/8 page ad:
Congratulations Sara!
1/4
page ad:
Fullpage:
page: $100
$325
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approximately 4”x 5 1/2”
Due:
October
17th, 2014*
1/2
page:
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150
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Payment:
Full
page: $325
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approximately 4” x 2.5”
Create
and October
pay
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ad online at:
Due:
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17th,
Friday,
31, 2014
www.yearbookordercenter.com
Payment:
Create and pay for your ad online at:
How to Submit Online:
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Log on to www.yearbookordercenter.com and enter
ordertonumber
12547.
How
Submit
Online:
Log on to www.yearbookordercenter.com and enter
Click Create a Yearbook Ad (see Ex. 1 below).
order number 12547.
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You have had such an amazing year! We are so proud of all of
your accomplishments. You really have turned out to be such
an amazing young woman and we couldn’t be happier for you.
We know you have a wonderful future ahead of you and can’t
wait to see what you accomplish!
Love, Mom, Dad, Johnny and Fluffy
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LINDBERGH HIGH SCHOOL
5000 Lindbergh Blvd.
St Louis, MO 63126
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Message Details:
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$ 260
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How
to Submit
Online:
Due:
FRIDAY,
DECEMBER
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Watch VideoGuidelines:
or Online Ad Creation Guide links.
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(See
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3
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in the yearbook.
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exactly
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want
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appear
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or
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in the yearbook. You will have final approval before is
you
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approval
before
or edit any portion of your message or photo that is
unacceptable
for
publication.
you
submit your
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unacceptable
forad.
publication.
or edit any portion of your message or photo that is
unacceptable for publication.
Full page ad: approximately 8.33" x 10.67”
Stephanie, you’re such an
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accomplished in your life
next. Love you!
Love, Mom & Dad
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5.25”
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krigerv@mdusd.org.
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at carrierapp@lindberghschools.ws
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at
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at: 877.362.7750
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accepted
on a space-available
plant ads
deadline,
we can no
accept ads.
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on longer
a space-available
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guarantee
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your
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your17th.
space!
31st
NO
ACCEPTED
AFTER
OCTOBER
31st
NO ADS ACCEPTED AFTER OCTOBER 17th.
$50 LATE FEE APPLIES TO ALL ADS FINISHED AFTER DECEMBER 11
1. Click here to purchase
your yearbook ad.
1. Click here to purchase
1. Click here
purchasead.
yourtoyearbook
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to watch
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video or download a PDF
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2.
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creation process.
•
*• *
YEARBOOK
RD
EARLY IBNIG
PRIC !!
NOW
ORDER NOW!
Buy your 2016 TIMBERLAND yearbook!
ORDER by AUGUST 31 to save $10!
OPTION 1 - ORDER ONLINE OR BY PHONE
To order your yearbook using a CREDIT CARD (NO transaction fees will apply):
1. Go to www.yearbookordercenter.com.
2. Enter Order Number 8123.
3. Follow the on-screen instructions.
Yearbook
If you do not have Internet Access, to use a credit card to order your yearbook,
call 1.866.287.3096 and use order number 8123.
OPTION 2 - ORDER AT SCHOOL BOOK STORE
To order your yearbook at school, please complete the following information
and return to the OFFICE
Nameplate
_______________________________________________________________
NAME (PLEASE PRINT)
____________________ GRADE
Return this order form with a check for the amount shown below to THE OFFICE DURING REGISTRATION.
Please make your check payable to HERFF JONES YEARBOOKS.
I want to order: (check all that apply)
Autograph Supplement
ALL COLOR YEARBOOK* ($50.00)
WORLD YEARBOOK ($5.00)
*16 page world news magazine
*After Aug. 31, price increases to $55
One Line Nameplate
($5.00)
Two Line Nameplate
AUTOGRAPH SUPPLEMENT ($3.00)
*Will deliver in May for signing.
($7.00)
HOME SHIPPING ($8.00)
*Book will be shipped to home - great for Seniors!
Address
for Shipping: _____________________
_________________
I have included a check for: ______
PLEASE MAKE CHECKS PAYABLE TO HERFF JONES YEARBOOKS.
If you chose to personalize your yearbook with a Name Plate, please print your name as you would like it to appear on
the line below. The maximum number of characters you may use is 30 per line, including spaces.
LINE 1
LINE 2
**Yearbook prices will increase incrementally
throughout the school year. Order NOW to receive
the best price.**
THE DENTIST IS COMING TO SCHOOL
AT NO COST * TO YOU!
Taking care of your child’s teeth is important to keep them healthy.
Please complete, sign & return to your teacher in 2 days
Includes initial dental care & follow-up visits!
1. ABOUT YOUR CHILD
If your child already sees a dentist regularly, continue to go to that dentist.
School or Program Name___________________________________________________________County___________________
Teacher_________________________________________________________ Room #__________Grade___________ AM/PM
Child’s Legal Name____________________________________________ Child’s Date of Birth________________ Male/Female
Child’s Social Security Number ______ ______ ______ - ______ ______ - ______ ______ ______ ______
(circle one)
Parent/Guardian Name_____________________________________________________________________________________
(PRINT CLEARLY & SIGN BELOW)
Address____________________________________________________City/Zip______________________________________
Email______________________________________ Phone (
) __________________
MEDICAID & CHIP COVER 100% OF TREATMENT
2. INSURANCE INFORMATION
CHILD HAS MEDICAID/CHIP
Enter Child’s 8-digit
ID Number HERE:
)_______________ Alt. Phone (
Circle one of the following: Missouri Medicaid (MO HealthNet), HealthCare USA, Missouri Care, Home State Health Plan
*If your child is insured by Medicaid or CHIP.
Ins. Company name (other than Medicaid)________________________________________________ Ins. Phone________________________
Group #_________________________________Employer name________________________________Co. phone_________________________
Name of Insured Adult________________________________________________________ BIRTH DATE of Insured Adult _________________
Member ID/Policy #______________________________________________ Social Security # of insured adult_____________________________
If paying for services, please make check or money order payable to Nevin Waters, DDS, PA & staple to this form.
II am
a dental for
cleaning,
screening
fluoride per
visit. per visit.
am able
able to
to pay
pay the
the full
full fee
fee for
of $133.00
a dental
cleaning,&screening
& fluoride
CHILD
CHILD HAS
HAS NO
NO DENTAL
DENTAL INSURANCE
INSURANCE
IIcertify
I need
to pay
for a$60.00
subsidized
because
I am unable
to pay
theunable
full fee.to
It will
dental
screening
& cleaning,
fluoride per visit.
certifythat
that
I need
to pay
for aservice
subsidized
service
because
I am
paycover
the full
fee.cleaning,
It will cover
dental
screening & fluoride per visit.
II certify
nancial assistance,
uoride
certify that
that II am
am unable
unable to
to pay
pay the
the full
full or
or subsidized
subsidized fee
fee and
and request
request full
full fifinancial
assistance, which
which will
will cover
cover dental
dental cleaning,
cleaning, screening
screening && flfluoride
(charity
(charity care
care unavailable
unavailable for
for restorative
restorative treatment).
treatment). We
We will
will send
send you
you aa charity
charity care
care application.
application. Charity
Charity care
care available
available only
only once
once per
per school
school year.
year.
3. CHILD’S MEDICAL HISTORY
CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD
Notify us of any medical history changes.
List allergies (including allergies to medications) __________________________
Name/phone # of child’s physician______________________________________
___________________________________________________________
Use space below to provide additional details on your child’s health, including current medical
treatment, other significant past illnesses, alcohol & tobacco use (including smokeless). List current
medications. Attach another page as needed.__________________________________
____________________________________________________________
Recent Dental Problems
Sickle Cell Anemia
Asthma or Wheezing
Fainting /Epilepsy/Seizures
Behavioral Problems
Liver Problems/Hepatitis
Communicable Diseases/TB
Kidney Problems
Rheumatic Fever
HIV/AIDS
Diabetes
Cancer
Hemophilia/Bleeding Problems
Heart Problems - Describe ___________________________________
Approx. date of last dental visit. _________
CHECK IF ANTIBIOTIC PRE-MEDICATION REQUIRED FOR DENTAL TREATMENT
4. READ AND SIGN BELOW
I request that the dentist perform a dental check-up on my child at school which includes exam, cleaning, fluoride, sealants and x-rays as needed, as well as other dental
work as needed, including fillings, extractions of infected baby teeth, numbing the mouth and teeth and other procedures as described more fully on the back of this page.
This permission includes future dental visits. I have read the IMPORTANT NOTICE AND CONSENT ON THE BACK OF THIS PAGE and understand and agree to its terms.
SIGN & DATE HERE ___________________________________________________________ ____________
DATE
QUESTIONS:1-888-833-8441 Fax:1-888-330-4331
Nevin Waters, DDS, PA
435 Nichols Road, Suite 200, Kansas City, MO 64112
©Nevin Waters, DDS, PA, 2013
MO-COMPR-008-PDF
For your privacy, please fold & secure.
FOLD
FOLD
CHILD HAS PRIVATE DENTAL INSURANCE
IMPORTANT NOTICE & CONSENT / AVISO IMPORTANTE Y CONSENTIMIENTO
I understand and authorize Nevin Waters, DDS, PA (Provider) and its affiliated dentists 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. I authorize the dentist to fill any cavities or to
place a crown over the tooth if needed. I authorize Provider to extract any problem baby teeth or perform a pulpotomy (treatment of the nerves inside the tooth) as needed.
I understand that there are risks to dental treatment including swelling or pain that may occur from the injection of a local anesthetic or allergic reaction. (For additional
information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize & direct Provider to bill & collect payment from any
Medicaid, insurance, or other payer. 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. 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 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 dental visit & follow-up visits. I may withdraw this consent at any time in writing to the address below.
Entiendo y autorizo a Nevin Waters, DDS, PA (Proveedor) y a sus dentistas afiliados a proveer los siguientes servicios al niño(a) mencionado del cual soy el padre custodio o tutor legal:
examen dental, limpieza de los dientes, tratamiento de fluoruro, rayos-x y sellantes. Autorizo al dentista a que atienda cualquier carie o coloque una corona sobre el diente si es 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 de abajo.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado o
tercera persona. 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. 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(a), incluyendo los registros obtenidos de otros proveedores, y cualquier otra
enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisión sexual, drogas, alcohol, y anemia. Yo autorizo la divulgación de dicha información por parte
de proveedores para cualquier pagador responsable y/o proveedor de servicios administrativos y de sus subcontratistas para el uso y divulgación de información relacionada con el
tratamiento de mi hijo(a), pago para el mantenimiento y operación de cuidado dental. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Puedo
retirar mi consentimiento en cualquier momento por escrito a la dirección abajo.
KEEP FOR YOUR RECORDS
DR. NEVIN WATERS, DDS, PA
William Dillon, DDS, Perdita J Fisher, DMD, Andrea Gordon, DDS, Joseph Hughey, DDS, Adrienne Jennings, DDS, Maria Wong Kim, DMD, Eric Klumb, DDS, Joel Luedeke, DMD, Ronald Parkin, DMD, Cory Scanlon, DDS, Ronald Shrum, DDS,
Deedra Truschinger, DDS, Hillard Ullman, DDS, Jennifer Waller-Smith, DDS, Dewain Whitmore, DDS
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. KEEP FOR YOUR RECORDS
OUR LEGAL DUTY
The privacy of your medical information is important to us. We are required by applicable federal and state law to
maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices,
our legal duties, and your rights concern¬ing your health information. We must follow the privacy practices that are
described in this Notice while it is in effect. We will notify you if your unsecured medical information is breached.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices
and the new terms of our Notice effective for all health information that we maintain, including health information
we created or received before we made the changes. Before we make a significant change in our privacy
practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for
additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations.
For example:
Treatment: We may use or disclose your health information to a physician, school nurse, or other healthcare
provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
S
D
R
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as
voicemail messages, postcards, letters, emails or text messages).
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for
the government to monitor the health care system, the outbreak of disease, government programs, compliance with civil rights laws
and to improve patient outcomes.
O
C
Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We may
also disclose health information about you in response to a subpoena, discovery request or other lawful process.
RE
Other Uses and Disclosures. As permitted or required by law, we may use or disclose your medical information for research
purposes; to organizations that handle and monitor organ donation and transplantation; for workers’ compensation or similar
programs to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries
or illness; for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications or
problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed
to, or is at risk for contracting or spreading, a disease; to medical examiners to identify a deceased person or determine cause of
death; or to funeral directors to carry out their duties.
R
U
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in
writing to obtain access to your health information and fax your request to the number at the end of this Notice.
YO
Healthcare Operations: We may use and disclose your health information in connection with our business
operations such as reviewing the competence or qualifications of healthcare professionals and evaluating
practitioner and provider performance.
Disclosure Accounting: You have the right to receive a list of some disclosures we or our business associates have made of your
health information. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests.
Your Authorization: Uses or disclosures not otherwise described in this Notice may be made only with your
written authorization. In addition, we must obtain your written authorization to sell your medical information
or to use or disclose your information for marketing goods or services to you where we are paid to make the
communication. If you give us an authorization, you may revoke it in writing at any time. Your revocation
will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give
us a written authorization, we cannot use or disclose your health information for any reason except those
described in this Notice.
Restriction: You have the right to request that we restrict our use or disclosure of your health information. We are not required to
agree to your request except when disclosure would be to your health plan, you (or someone on your behalf other than your health
plan) has paid in full for your health care, the disclosure relates to payment or health care operations, and the disclosure is not
otherwise required by law. If we agree to the restriction, however, we will abide by that agreement (except in an emergency).
To Your Family and Friends and Persons Involved in Your Care: We may disclose your health information to a
family member, friend or other person involved in your care to the extent necessary to help with your healthcare or
with payment for your healthcare. We may also disclose your medical information to disaster relief organizations to
help locate individuals during a disaster. We may also use or disclose your medical information to notify, or assist
in the notification, of a family member, a personal representative or a person responsible for your care of your location,
general condition or death. If you do not want us to disclose your medical information to family members or others in
these circumstances, please notify our HIPAA Officer at 623-434-9343 x1152.
Amendment: You have the right to request that we amend your health information. Your request must be in writing and must
explain why the information should be amended. We may deny your request under certain circumstances.
P
E
R
O
F
KE
Required by Law: We may use or disclose your health information when we are required to do so by law.
Public Safety: We may need to disclose medical information to law enforcement officials, such as in
response to a search warrant or a grand jury subpoena, or to assist law enforcement officials in identifying or
locating an individual, to report deaths that may have resulted from criminal conduct, and to report criminal
conduct on our premises.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose your medical information to military authorities of Armed Forces or foreign military personnel
under certain circumstances; to authorized federal officials for lawful intelligence, counterintelligence, or other national security
activities, and to protect the president; and to a correctional institution or law enforcement official having lawful custody of an
inmate or patient under certain circumstances.
Alternative Communication: You have the right to request in writing that we communicate with you about your health information
by alternative means or to alternative locations specified in your written request.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in
written form upon request.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are con-cerned
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.
Phone: 623-434-9343 x1152
email: hipaaofficer@smileprograms.com
Effective Date: August 1, 2013
¡EL DENTISTA VIENE A LA ESCUELA
SIN NINGÚN COSTO* PARA USTED!
Cuidar de los dientes de su niño(a) es importante para mantenerlos sanos
Por favor llene, firme y regrese a su maestro(a) en 2 días
¡Incluye atención dental inicial y visitas de seguimiento!
1. DIGANOS ACERCA DE SU NIÑO(A)
Si su hijo(a) ya visita un dentista regularmente, continúe con ese dentista.
Escuela o Nombre del Programa___________________________________________________ Condado___________________
Profesor_____________________________________________________________ # de Salón_______Grado_______ AM/PM
Nombre Legal del Niño(a)____________________________________________ Fecha de Nacimiento_________ Hombre/Mujer
(circule uno)
Seguro Social ______ ______ ______ - ______ ______ - ______ ______ ______ ______
Padre/Tutor Legal_________________________________________________________________________________________
ESCRIBA CLARO Y FIRME ABAJO)
Dirección_________________________________________________Ciudad/Código Postal_____________________________
Email___________________________________ Teléfono (
)_______________ Teléfono Alt. (
) __________________
2. INFORMACION DEL SEGURO MEDICAID Y CHIP CUBREN 100% DEL TRATAMIENTO
NIÑO(A) TIENE MEDICAID/CHIP
Escriba los 8-digitos # de
identificación del niño(a) AQUI
Circule uno de los siguientes: Missouri Medicaid (MO HealthNet), HealthCare USA, Missouri Care, Home State Health Plan
*Si su hijo(a) está asegurado por Medicaid o CHIP.
Nombre de la Comp. de Seguro (aparte de Medicaid)______________________________________ Tel. del Seg.________________________
# Grupo_________________________________Empleador________________________________Tel. del Empleador______________________
Nombre del Adulto Asegurado___________________________________________ FECHA DE NACIMIENTO del adulto Asegurado _________
# Póliza/ID__________________________________________ Seguro Social del Adulto Asegurado_____________________________________
DOBLE
DOBLE
NIÑO(A) TIENE SEGURO DENTAL PRIVADO
NIÑO(A) NO
NO TIENE
TIENE SEGURO
SEGURO DENTAL
DENTAL Si va a pagar por los servicios, por favor haga su cheque o giro postal a Nevin Waters, DDS, PA y engrápelo a esta forma.
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el costo
costo completo
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3. HISTORIA MEDICA DEL NIÑO(A)
Notifíquenos de cualquier cambio en el historial medico.
Liste alergias (incluya alergias a algún medicamento)__________________________
Nombre y # de Teléfono del Doctor______________________________________
Celula de la Hoz
Anemia/Ataques epilépticos /Desmayos ___________________________________________________________
Use el espacio de abajo para darnos información adicional sobre la salud de su niño(a), incluyendo cualquier
Problemas del Riñon
Problemas del Hígado/Hepatitis tratamiento que este recibiendo, alguna otra enfermedad de significado, uso de alcohol o tabaco (incluyendo
el que no se fuma). Liste todos los medicamentos que esta tomando. Adhiera otra página si es necesario.
VIH/SIDA
____________________________________________________________
UNICAMENTE SELECCIONE LA CONDICION(ES) QUE APLIQUE(N).
Problemas dentales recientes
Asma o problemas de respiración
Problemas de comportamiento
Enfermedades Transmisibles/TB
Fiebre Reumática
Cáncer
Diabetes
Hemofilia o problemas de sangrado
Problemas del Corazón. Describa ___________________________________ Fecha aprox. de la ultima visita dental _________
MARQUE SI REQUIERE ANTIBIOTICO ANTES DE OBTENER TRATAMIENTO DENTAL
4. LEA Y FIRME ABAJO
Solicito que el dentista realice una revisión dental a mi hijo(a) en la escuela la cual cubrirá el examen dental, limpieza, fluoruro, sellantes, y rayos-x como sean
necesarios, así como otros trabajos dentales según la necesidad, incluyendo rellenos, extracciones de dientes de leche infectados, adormecimiento de la boca y
dientes y otros procedimientos como se describe con más detalles en la parte posterior de esta página. Este permiso incluye visitas al dentista en el futuro. He leído
la ADVERTENCIA IMPORTANTE Y CONSENTIMIENTO EN LA PARTE POSTERIOR DE ESTA PAGINA, entiendo y estoy de acuerdo con sus términos.
FIRME Y FECHA AQUI ___________________________________________________________ ____________
FECHA
Preguntas: 1-888-833-8441 Fax:1-888-330-4331
Nevin Waters, DDS, PA
435 Nichols Road, Suite 200, Kansas City, MO 64112
©Nevin Waters, DDS, PA, 2013
MO-COMPR-008-PDF
Para su privacidad doble y asegure.
IMPORTANT NOTICE & CONSENT / AVISO IMPORTANTE Y CONSENTIMIENTO
I understand and authorize Nevin Waters, DDS, PA (Provider) and its affiliated dentists 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. I authorize the dentist to fill any cavities or to
place a crown over the tooth if needed. I authorize Provider to extract any problem baby teeth or perform a pulpotomy (treatment of the nerves inside the tooth) as needed.
I understand that there are risks to dental treatment including swelling or pain that may occur from the injection of a local anesthetic or allergic reaction. (For additional
information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize & direct Provider to bill & collect payment from any
Medicaid, insurance, or other payer. 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. 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 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 dental visit & follow-up visits. I may withdraw this consent at any time in writing to the address below.
Entiendo y autorizo a Nevin Waters, DDS, PA (Proveedor) y a sus dentistas afiliados a proveer los siguientes servicios al niño(a) mencionado del cual soy el padre custodio o tutor legal:
examen dental, limpieza de los dientes, tratamiento de fluoruro, rayos-x y sellantes. Autorizo al dentista a que atienda cualquier carie o coloque una corona sobre el diente si es 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 de abajo.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado o
tercera persona. 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. 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(a), incluyendo los registros obtenidos de otros proveedores, y cualquier otra
enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisión sexual, drogas, alcohol, y anemia. Yo autorizo la divulgación de dicha información por parte
de proveedores para cualquier pagador responsable y/o proveedor de servicios administrativos y de sus subcontratistas para el uso y divulgación de información relacionada con el
tratamiento de mi hijo(a), pago para el mantenimiento y operación de cuidado dental. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Puedo
retirar mi consentimiento en cualquier momento por escrito a la dirección abajo.
MANTENGA PARA SUS ARCHIVOS
DR. NEVIN WATERS, DDS, PA
William Dillon, DDS, Perdita J Fisher, DMD, Andrea Gordon, DDS, Joseph Hughey, DDS, Adrienne Jennings, DDS, Maria Wong Kim, DMD, Eric Klumb, DDS, Joel Luedeke, DMD, Ronald Parkin, DMD, Cory Scanlon, DDS, Ronald Shrum, DDS,
Deedra Truschinger, DDS, Hillard Ullman, DDS, Jennifer Waller-Smith, DDS, Dewain Whitmore, DDS
AVISO SOBRE PRACTICAS DE PRIVACIDAD
ESTE AVISO DESCRIBE CÓMO SU INFORMACIÓN MÉDICA PUEDE SER USADA Y DIVULGADA, Y COMO USTED PUEDE OBTENER ACCESO A DICHA
INFORMACIÓN. POR FAVOR LEA ATENTAMENTE. MANTENGA PARA SUS ARCHIVOS
NUESTRO DEBER LEGAL
La privacidad de su información médica es importante para nosotros. Somos requeridos por leyes federales y estatales aplicables a mantener
la privacidad de su información de salud. También somos requeridos a darle este Aviso acerca de nuestras prácticas de privacidad,
nuestros deberes legales y sus derechos respecto a su información de salud. Debemos seguir las prácticas de privacidad descritas en
este Aviso mientras se mantenga en efecto. Le notificaremos si es violada su información médica.
Reservamos el derecho de cambiar en cualquier momento los términos y prácticas de privacidad de este Aviso mientras tales cambios
sean permitidos por las leyes aplicables. Reservamos el derecho de hacer cambios eficazmente en nuestras prácticas de privacidad y los
nuevos términos de nuestro Aviso para toda la información médica que mantenemos, incluyendo información de salud creada o recibida
antes de hacer los cambios. Antes de efectuar algún cambio significante a nuestras prácticas de privacidad, cambiaremos este Aviso y lo
haremos disponible a su pedido.
Puede solicitar una copia de nuestro Aviso en cualquier momento. Para más información de nuestras prácticas de privacidad, o para
copias adicionales de este Aviso, por favor póngase en contacto con nosotros usando la información que aparece al final de este Aviso.
USO Y DIVULGACION DE INFORMACION DE SALUD
Usamos y damos su información de salud para fines de tratamiento, facturación y operaciones de salud. Por ejemplo:
Tratamiento: Podemos usar o dar su información de salud a su médico, enfermera de la escuela o otro proveedor de salud que le esté
proveyendo tratamiento.
Pagos: Podemos usar y dar su información de salud con fines de obtener pago por los servicios proveídos por nosotros a usted.
Operaciones de Atención Médica: Podemos usar y dar su información médica con respecto a nuestras operaciones de negocio tales
como revisión de competencia o calificación de los profesionales de salud y evaluación del rendimiento profesional y proveedor.
Su Autorización: Usos o divulgaciones no descritas en esta notificación pueden hacerse solo con su autorización por escrito. Además,
debemos obtener su autorización por escrito para vender su información médica o para usar o dar su información para la comercialización
de bienes o servicios a usted donde nos pagan para hacer la comunicación. Si usted nos da una autorización, usted puede anularla
por escrito en cualquier momento. Su anulación no afectara cualquier uso o divulgación permitida por su autorización, mientras este en
efecto. A menos que usted nos dé una autorización por escrito, no podemos usar o divulgar su información médica por cualquier motivo
excepto los descritos en este Aviso.
A Su Familia y Amigos y Personas Involucradas en su Cuidado: Podemos dar su información médica a un familiar, amigo o otra
persona involucrada en su cuidado en la medida necesaria para ayudar con su salud o con el pago de su atención médica. También
podemos dar su información médica a organizaciones de ayuda de desastre para ayudar a localizar a individuos durante un desastre.
También podemos utilizar o divulgar su información médica para notificar, o asistir en la notificación, de un miembro de la familia, un
representante personal o una persona responsable de la localización de su cuidado, condición general o muerte. Si no desea que demos
su información médica a miembros de la familia o otras personas en estas circunstancias, por favor notifique a nuestro oficial de HIPAA al
623-434-9343 x1152.
Requerido por La Ley: podemos utilizar o dar su información médica cuando estemos obligados a hacerlo por ley.
Seguridad Pública: Podremos dar información médica a oficiales la ley, para responder a una orden de allanamiento o una citación
del gran jurado, o para ayudar a los oficiales de ley a identificar o localizar a un individuo, o para reporte de una muerte que pudo haber
resultado por conducta criminal e informar una conducta criminal en nuestras instalaciones.
Abuso o Negligencia: Podemos dar su información médica a autoridades apropiadas si razonablemente creemos que usted es una víctima
de abuso, negligencia o violencia doméstica o la posible víctima de otros delitos. Podemos dar su información de salud en la medida
necesaria para evitar una amenaza grave para su salud o seguridad o la salud o la seguridad de los demás.
Seguridad Nacional: Podemos dar su información médica a las autoridades militares de las fuerzas armadas o de personal militar
extranjero bajo ciertas circunstancias; a funcionarios federales de la ley de inteligencia legal, contrainteligencia y otras actividades de
seguridad nacional y para proteger al Presidente; y a un oficial de la ley o institución correccional que tiene la tutela legal de un preso o
paciente bajo ciertas circunstancias.
Recordatorios de citas: Podemos utilizar o dar su información médica para proporcionarle recordatorios de citas (por ejemplo, mensajes
de voz, tarjetas postales, cartas, correos electrónicos o mensajes de texto).
Actividades de Supervisión de Salud: Podemos dar información médica a una agencia de supervisión de salud para actividades
autorizadas por la ley. Estas actividades de supervisión por ejemplo incluyen, auditorías, investigaciones, inspecciones y encuesta de
licencia. Estas actividades son necesarias para el gobierno para controlar el sistema de salud, el brote de enfermedades, programas de
gobierno, el cumplimiento de las leyes de derechos civiles y para mejorar los resultados del paciente.
Demandas y Disputas: Podemos dar información médica sobre usted para responder a una orden judicial o administrativa. También
podemos dar información médica sobre usted en respuesta a una citación, solicitud de descubrimiento o otro proceso legal.
Otros Usos y Revelaciones: Podemos utilizar o dar su información médica para fines de investigación; a las organizaciones que manejan
y monitorear la donación de órganos y trasplante, como sea permitido o requerido por la ley; para la compensación de trabajadores o
programas similares a cumplir con las leyes relacionadas con la compensación de trabajadores o programas similares que proporcionan beneficios
para lesiones relacionadas con el trabajo o la enfermedad; para actividades de salud pública tales como para prevenir o controlar
enfermedades, lesiones o incapacidades; para reportar reacciones a medicamentos o problemas con productos; notificar a las personas
de revocaciones de productos que pueden estar usando; para notificar a una persona que pudo haber sido expuesta a, o corre el riesgo
de contraer o esparcir una enfermedad; a médicos forenses para identificar a una persona fallecida o determinar causa de muerte; o a
directores de funerarias para llevar a cabo sus funciones.
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DERECHOS DEL PACIENTE
Acceso: Usted tiene el derecho a ver o obtener copias de su información médica, con excepciones limitadas. Usted debe hacer
una petición por escrito para obtener acceso a su información de salud y enviar su solicitud por fax al número al final de este
Aviso.
Contabilidad de Divulgación: Usted tiene el derecho a recibir una lista de algunas revelaciones que hemos hecho nosotros o
nuestros asociados de negocios de su información médica. Si usted ha solicitado esta información más de una vez en un período
de 12 meses, podríamos cobrarle una cuota razonable, basado en los costos para responder a estas solicitudes adicionales.
Restricciones: Usted tiene el derecho a solicitar que restrinjamos el uso o divulgación de su información de salud. No estamos
obligados a aceptar su solicitud, excepto cuando la divulgación sería a su plan de salud, usted (o alguien en su nombre que no
sea su plan de salud) ha pagado total para el cuidado de su salud, la divulgación se refiere al pago o operaciones de cuidado
de la salud, y la divulgación de lo contrario no es requerida por ley. Sin embargo, si estamos de acuerdo a la restricción, nos
regiremos por ese acuerdo (excepto en caso de emergencia).
Comunicación Alternativa: Usted tiene el derecho de solicitar por escrito que nos comuniquemos con usted acerca de su
información médica por medios alternativos o a lugares alternativos especificados en su petición.
Enmienda: Usted tiene el derecho de solicitar que nosotros enmendemos su información de salud. Su petición debe ser por
escrito y debe explicar por qué se enmiende la información. Podemos negar su petición bajo ciertas circunstancias.
Aviso Electrónico: A su petición, usted tiene derecho a recibir esta notificación por escrito, si usted recibe este Aviso en nuestro
sitio Web o por correo electrónico (e-mail).
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PREGUNTAS Y QUEJAS
Si desea más información sobre nuestras prácticas de privacidad o tiene preguntas o inquietudes, por favor comuníquese con
nosotros. Si usted está preocupado que podemos haber violado sus derechos de privacidad, puede quejarse con nosotros por
medio la información que aparece al final de este Aviso. Usted también puede presentar una queja por escrito al Departamento
de Salud y Servicios Humanos de los Estados Unidos. No tomaremos represalias de ninguna manera si usted decide presentar
una queja con nosotros o con el Departamento de Salud y Servicios Humanos de los Estados Unidos.
Contacto oficial: Oficial de HIPAA
Teléfono: 623-434-9343
email: hipaaofficer@smileprograms.com
Fecha efectiva: August 1, 2013