COLLEEN COURNOT, DDS

Appointments & Forms

Welcome to our practice! The entire team would like to thank you for selecting our office to care for your dental needs. We are committed to providing superior quality dental care in a gentle, effective,pleasant manner and are proud of our dedication to our patients.  Our hope is to create a dynamic partnership dedicated to your oral health care.

At your initial visit, you will have an opportunity to tell Dr. Cournot about yourself and your goals for a healthier smile.  Dr. Cournot will begin with a  comprehensive oral exam which includes a screening of your head and neck muscles, lymph nodes and temporomandibular joint (jaw joints). An oral cancer screening, periodontal exam (examination of your gums) and an occlusal screening (examination of your bite) will also be provided. We also will review your medical & dental history and take this into consideration when devising a plan for long term health. Last but not least, a thorough examination of your teeth for cavities, cracks and the stability of your existing restorations will be performed.  At this visit, a complete set of digital x-rays and digital photos will be taken to ascertain the proper diagnosis and treatment goals. We will assess your risk for future cavities and gum disease by inquiring about your family history, medical history, dental history, current oral home care routine and nutritional habits.  A report of all the information gathered will be organized, written and summarized in a "Diagnostic Report of Findings” that is sent to you via mail or email.

At the second visit, Dr. Cournot will present and discuss the results of your exam.  Together, you and Dr. Cournot will plan a course of treatment that suits your individual needs. At that time, your hygiene treatment will be appointed with our hygienist, Debra.  The treatment planning session and your hygiene visit may be combined if your schedule permits. 

Your oral health is a vital part of your over all well being. We are committed to helping you achieve a healthier and a more beautiful smile that can positively impact your life forever.

Forms

Get a head start on your initial visit by completing the Patient Registration and Dental & Medical History forms.

Download the attached documents, enter the required information, and email the forms to our office two days prior to your appointment so that Dr. Cournot and her team can better prepare for your visit.

Patient Registration Form

Dental History Form

Medical History Form

Instructions: In order to save your completed documents, click “File” and select “Save As.” Incorporate your last name into the “File name” and click “Save.” Email the forms back to drcournot@drcournot.com as an attachment.

Also, please review the Notice of Privacy Practices (below) before your appointment. We request that you sign the hard copy at check-in.

Because we are dedicated to providing our patients with the best dentistry and service available, it is not our policy to schedule several patients at the same time. This appointment is reserved exclusively for you. If you find that you cannot keep your scheduled appointment, we require 2 working days notice to avoid a $75.00 cancel fee. This permits another patient to receive dental care in your absence. Should you have any questions, please call our office.

Notice of Privacy Practices & Consent for Treatment

Protecting Your Confidential Health Information is Important to Us

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.

Dear Patient:

It is our desire to communicate to you that we are taking the new Federal HIPAA (Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside our office.

So what has changed?

The most significant variable that has motivated the Federal government to legally enforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the Internet, phone, faxes, copy machines, and charts. We believe this has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we use to ensure the protection of your health information everywhere it is used.

We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment, and conducting health care operations. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

How your HEALTH INFORMATION may be used

To Provide Treatment

We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business officer staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies, or other health care personnel providing your treatment.

To Obtain Payment

We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

To Conduct Health Care Operations

Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders, or electronic reminders such as email (unless you tell us that you do not want to receive these reminders).

Abuse or Neglect

We will notify government authorities if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient’s agreement.

Public Health and National Security

We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement

As permitted or required by State of Federal law, we may disclose your health information to a low enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Family, Friends, and Caregivers

We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want, we will use our very best judgment when sharing your health information only when it will be important to those participating in providing your care.

Authorization to Use of Disclose Health Information

Other than is stated above or where Federal, State, or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights

This new law is careful to describe that you have the following rights related to your health information.  You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

Confidential Communications

You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed, communications that are sealed. We will make every effort to honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information

You have the right to read, review, and copy your health information, including your complete chart, x-rays, and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your records if you believe your health information is incorrect or incomplete.  We will be happy to accommodate you as long as our office maintains this information.  In order to standardize our process, please provide us with your request in writing and describe your reason for the change.  Your request may be denied if the information record in question was not created by our office, is not part of records or if the records containing your health information are determined to be accurate and complete.

Documentation of Health Information

You have the right to ask us the description of how and where your health information was used by our office for any reason other than for treatment, payment or health operations. Our documentation procedures will enable us to provide information on health information usage from April 14^th, 2003 and forward.  Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time.  We may need to charge you for a reasonable fee for your request.

Request a Paper Copy of This Notice

You have the rights to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you. We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of Privacy Practices.  We are required to practice the required policies and procedures described in this notice but we do reserve the right to change the terms of our Notice.  If we change our privacy practices, a revised notice shall be distributed to all patients. 

You have the right to express complaints to us or to the secretary of Health and Human Services if you believe your privacy rights have been compromised.  We encourage you to express any concerns you may have regarding the privacy of you information. Please let us know of your concerns or complaints in writing.

Thank you very much for taking the time to review how we are carefully using you health information.  If you have questions, we want to hear from you.  If not, we would appreciate very much your acknowledging your receipt of our policy by signing below.

Patient Signature:   ___________________________________________Today’s Date:  ___________________________