D. Bartholomew G. Kreiner D.D.S. New Patient Child Form You're on step 1/8: Pediatric Dentistry Hisory Leave this field blank Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Age Who is accompanying the child today? Name? Parents marital status Choose Married Widow Divorced Parent Not Living With Child Name Who to contact in case of emergency if other than parent? (optional) Do you have dental Insurance? Choose Yes No Insured S.S # Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Secondary Insurance Choose Yes No Insured S.S # Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 PEDIATRIC DENTISTRY HISTORY (To be completed by parent or guardian) (optional) Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Age Is your child regularly seen by medical doctor or clinic? Yes No Date of last complete medical exam? Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Has your child ever been hospitalized, had general anesthesia, or emergency room visits? Yes No Medical History Does your child have or ever had any of the following? Yes No Frequent cold or ear infection? Yes No Strep throat or tonsilltis? Yes No Pneumonia or respiratory problems? Yes No Tuberculosis Yes No Allergies Yes No Asthma Yes No Eye problem Yes No Stomach problem or frequent vomiting Yes No Liver disease, hepatitis or jaundice Yes No Diabetes Yes No Birth Defect Yes No Learning Disorder Yes No Heart Murmur or disease Yes No Sickle cell anemia or trait Yes No Transfusions Yes No Bruises easily or bleeds a lot? Yes No Scarlet fever or rheumatic fever Yes No Measles, mumps, or chicken pox Yes No Sexually Transmitted disease Yes No Seizures or epilepsy Yes No Emotional or behavioral problems Yes No Pregnancy Yes No Drug or alcohol abuse Yes No Use of tobacco products Yes No Physical abuse Yes No Regular injections or medications Yes No Immunizations Has your child had the following immunizations? Yes No DPT Yes No Oral polo Yes No Tetanus booster Yes No Measles Yes No Mumps Yes No Tuberculosis (Tine Test) Yes No Was it positive? Yes No Do any member of the household or other relatives have a history of: Yes No Congenital heart disease Yes No Hight blood pressure Yes No Blood disease Yes No Sever Allergies or asthma Yes No Mental retardation Yes No Seizures or convuisions Yes No Emotional Problems Yes No Cleft lip or pelate Yes No Diabetes Yes No Urine or kidney problems Yes No Alcohol Abuse Yes No Drug Abuse Yes No Sexually transmitted diseases Yes No Tuberculosis Yes No Severe gum disease or decay Yes No Other diseases Yes No Developmental History For Younger Children Baby born premature Yes No Problems during pregnancy or delivery Yes No Problems immediately after birth Yes No Rh or blood problem Yes No Feeding problems Yes No Did baby go home with mother from hospital? Yes No For All Children Was your child breast fed? Yes No When Stopped? Was your child bottle fed? Yes No When Stopped? Did your child use a pacifier? Yes No When Stopped? Did your child suck on their finger or thumb? Yes No When Stopped? Does your child attend any special classes or schools? Yes No What grade is your child in? For older children and adolescents Has your child recently started to grow quickly? Yes No Do you think your child has stopped growing? Yes No Do you have any records of your child's height or weight changes? Yes No Has your child shown any signs of reaching puberty? Ex.Girls monthly period; boys - shaving or voice change Yes No Dental History Is this your child's first visit to a dentist? Yes No Has your child had toothaches in the past? Yes No Does your child have pain now? Yes No Does your child think anything is wrong with his/her teeth? Yes No Has your child ever received trauma to teeth, mouth, or face? Yes No Do you think your child will react negatively (be upset) to dental treatment? Yes No Are you nervous about this treatment? Yes No Does your child brush his/her own teeth? Yes No Does your child use dental floss? Yes No Do you usually help your child brush? Yes No Does your child's gums bleed when brushed? Yes No Did you or your child ever get instructions for brushing? Yes No Does your child use fluoride products: rinses, drops, tabs? Yes No Signature of person completing form Start Drawing Clear Done Start Over D. Bartholomew G. Kreiner ,D.D.s (optional) Phone: (410) 879-1730 510 S. Fountain Green Road (optional) BelAir Maryland 21015 Contact Preference Dear Patient: (optional) In an effort to have Dr. Kreiner's office contact you to confirm appointments, follow up after a procedure or to remind you of overdue recare or treatment. Please choose how you would like to be contacted. Please feel free to choose as many as you like: Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Patient Signature Start Drawing Clear Done Start Over Financial Responsibility and Patient Consent Note: (optional) I understand that I am responsible for payment of services rendered, co-payments and deductible that my dental insurance does not cover. Co —payments and deductibles are due at the time of service. If payment is not received within 30 days from date of service, you will be assessed a 1.5% late charge of your unpaid balance or a S 5.00 billing fee whichever is greater, until balance is paid in full. Our contractual arrangements are with you are not your insurance company. Any checks returned will be subject to a S40.00 returned check fee. If your account becomes assigned to a collection agency, I agree to pay the cost of collection agency fees, court costs, and attorney fees. I authorize the dentist to release any information requested by any third party payor regarding charges incurred by the patient. I consent to all treatment, tests, and diagnostic procedures deemed necessary by the dentist. Absolutely no dental treatment will be started without my prior approval. Any appointment cancelled less than 48 hours in advance will be charged a cancelled appointment fee of $64.00 which is not covered by insurance. Any Scheduled appointment that the patient fails to appear with out notice will be charged a missed appointment fee of $64.00 which is not covered by insuranceI have read the above; I understand it and agree to the terms. Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Patient Signature Start Drawing Clear Done Start Over Financial Options Dear Patient: (optional) In an effort to provide you with payment arrangements, we have expanded our payment policy. FULL PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT We now offer the following payment options: Please make a choice, sign below and return to the office manager before treatment. Payment by cash Payment by Check Payment by Credit Card (Visa & MasterCard only) Guarantee any amount not covered by insurance with Visa or MasterCard Third Party Financing with Care Credit upon approval 12 month interest free if balance paid off in full within the 12 months for amounts starting at $1,000.00 or more. Note: (optional) Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance.If none of the above applies, please see the office manager. Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Patient Signature Start Drawing Clear Done Start Over CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT SECTION B: TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice 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 revisions of our Notice, at any time by contacting: (optional) Contact Person: NancyTelephone: (410) 879-1730Second Office Line: (410) 638-5000E-mail: Dr@bartkreinerdds.comAddress: 511 South Fountain Green Road Bel Air, Maryland #21015 Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. 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 you or to continue treating you 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 protected health information to carry out treatment, payment activities and heath care operations. Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Signature Start Drawing Clear Done Start Over If this Consent is signed by a personal representative on behalf of the patient, complete the following: @ 2002 American Dental AssociationAll Rights Reserved ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** (optional) Note: Privacy Policy - https://bartkreinerdds.com/privacy-policy/ I have received a copy of this office's Notice of Privacy Practices. Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Signature Start Drawing Clear Done Start Over NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY 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 concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/2003, and will remain in effect until we replace it. 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 infomation 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 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.Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, cedification, licensing or credentialing activities.Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. 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.To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health infomation to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.Persons Involved In Care: We may use or disc;ose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.Required by Law: We may use or disclose your health information when we are required to do so by law.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 to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patient under certain circumstances.Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health inforrnation, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you SO. for each page, S per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to altemative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.Amendment: You have the right to request that we amend your health infomation. (Your request must be in writing, and it must explain why the infomation should be amended.) We may deny your request under certain circumstances.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. 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, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may subrnit a written complaint to the IJ.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: NancyTelephone: (410) 879-1730 Second Line : (410) 638-5000E-mail: Dr@bartkreinerdds.com Address: 511 South Fountain Green Road Bel Air, Maryland #21015 @ 2002 American Dental Association Continue
