Office Forms

Please print these forms and bring them with you to your first visit!

Insurance Questions

We do accept some insurance plans but coverage changes often. To help you better understand the process, use the link below or call our office at 831-662-2900.

Account Information

Need a form? Have a question about office policies? Find the answers here!

Office Policies

Please review our policies below. If you have questions feel free to contact us.

Scheduling Appointments

The office attempts to schedule appointments at your convenience and when time is available. Preschool children should be seen in the morning because they are fresher and we can work more slowly with the child for their comfort. School children who need treatment should be seen in the morning for the same reason. Dental appointments are an excused absence. Missing school can be kept to a minimum when regular dental care is continued.
Since appointed times are reserved exclusively for each patient we ask that you please notify our office 24 hours in advance of your scheduled appointment time if you are unable to keep your appointment. Another patient who needs our care could be scheduled if we have sufficient time to notify them. We realize that unexpected things happen, but we ask for your assistance in this regard.
Please be on time for your appointment. We make every effort to run on time so that we can minimize your wait. To help achieve this goal, we have a strict tardy policy. If you are late your appointment will be rescheduled.

Staying with your child

It is our policy to allow parents to stay with their child during procedures if they wish. Dr. Jackson and her staff will explain the procedures and answer your questions as they come up. We feel this is the best way to provide a positive experience for both patients and parents. If you're not comfortable in the back office, that is okay too.

Financial and Cancellation Policies

1. All professional fees are due at the time of service.
2. For patients with insurance:
a. Co-payments and deductibles are due at the time of service.
b. Any unanticipated amounts, not paid by your insurance company, are your responsibility.
c. After (60) days, all outstanding balances, including outstanding insurance claims, are due and payable by you.
d. As a courtesy to you, we will handle the insurance billing; however, it is not our obligation.
e. If your insurance company requests information from you, you must respond in a timely manner.
f. We recommend that you keep track of your benefits (such as maximums or eligibility requirements).
g. It is your responsibility to make sure your insurance is paying what they are supposed to. We will assist you as needed.
h. All recommended treatment is determined to be necessary for the oral health of your child. Failure of your insurance company to pay does not indicate the treatment can wait nor waive any of our fees.
3. We reserve exclusive time for your child's treatment. As a courtesy to our office and other patients, we require at least 24 hours notice to change or cancel appointments.
4. Parents or guardians must accompany the child or submit written treatment and financial consent at each and every visit.
5. There is a $20.00 fee for all returned checks.
6. It is Dr. Jackson's policy to inform all patients of the fees for the treatment planned. If for any reason we fail to inform you of the fees, it is your responsibility to ask.
--------------------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.

TO DOWNLOAD A COPY OF THIS POLICY, CLICK HERE.

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 10/1/2013, 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. 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 disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other healthcare providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription, or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.
Payment: We may use and disclose your health information to obtain payment for services we provide to you, unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered.
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, certification, 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. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends, or any other person identified by you.
Unsecured Email: We will not send you unsecured emails pertaining to your health information without your prior authorization. If you do authorize communications via unsecured email, you have the right to revoke the authorization at any time.
Persons Involved In Care:We may use or disclose 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 may contact you about products or services related to your treatment, case management or care coordination, or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination, or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without your written authorization. We will disclose whether we receive payments for marketing activity you have authorized.
Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Public Health: We may, and are sometimes legally obligated, to disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk or harm or would require informing a personal representative we believe is responsible for the abuse or harm.
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 patients under certain circumstances.
Appointment Reminders: We may contact you to provide you with appointment reminders via voicemail, postcards, or letters. We may also leave a message with the person answering the phone if you are not available.
Sign In Sheet and Announcement: Upon arriving at our office, we may use and disclose medical information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready to see you.
Open Office Environment: We will make every effort to keep your health, treatment, and/or payment information confidential. However, due to our open office environment, some information may be inadvertently overheard by other patients, their family or representatives.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, 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 $0.25 for each page, $20.00 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 October 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). In the event you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request.
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative 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.
Breach Notification: In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information 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 submit a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate in any way if you choose to file a complaint.
Contact Officer: ALISON K. JACKSON, D.D.S., A.P.C.
Telephone:(831) 662-2900 Fax: (831) 662-3978
Address: 7545 SOQUEL DRIVE, STE. A, APTOS, CALIFORNIA 95003

FAQs About Insurance

Insurance FAQs

Forms

Please print and fill out the following forms before your first visit. Thanks!