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Call us now: 816.741.5480
Patient Forms
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For your visit, we like to obtain important background information, such as your medical history and demographics, to help get better acquainted with you.

To help decrease your waiting time during your visit, you may print out and complete the necessary patient forms in advance and bring them with you to your appointment. You will also provide a printable map and driving directions below for your convenience.

Patient Information Form

Patient Medical History

Referral Form

Map & Directions

Our Privacy Practices Policy

This Notice of Privacy Practices describes how health information about you may be used and disclosed and how you may access this information.  We are required to post this information on our website to meet HIPPA regulations. The privacy of your health information is important to us and we will do all we can to help you understand your rights and our responsibilities to you as our patient.


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 September 15, 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 change. If we make a material change to our policy practices, we will provide a revised notice to you upon request. The effective date of a revised notice will be noted.

A copy of the current Notice in effect will be available at our dental practice location and on our website. You may request a copy of the current Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact our Privacy Officer using the contact information listed at the end of this Notice.

We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our patients' health information accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse.


Treatment: We may use or disclose your health information to another dentist, a physician or other health care provider providing treatment to you for the purpose of evaluating your dental health, diagnosing health conditions, and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed.

Payment: We provide dental services. Your health information may be used to seek payment from your insurance plan for the services we provide for you. Your insurance benefits provider may request and receive information from us on dates that you received services at our facility in order to allow your employer to verify and process your insurance claim. If your dental insurance coverage is through an employer's sponsored group dental plan, we may share summary health information with the plan sponsor.

Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care and dental care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. We may use and disclose your health information in connection with conducting or arranging medical reviews, audits, and legal services, including fraud and abuse detection and prevention as well as business planning, development, management, general administration including customer services, complaint resolutions and billing, de-identifying health information and creating limited data sets for health care operations, public health activities, and research. We may disclose your health information to our business associates that perform functions or provide services to assist in your treatment.

Your Authorization: You (or your legal representative) may give us written authorization to use your dental health information or to disclose it to anyone for any purpose. If you give us such 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 written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. When you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information.

Family, Friends and Others Involved in Your Care or Payment for Care: We must disclose your health information to you, as described in the Patient Rights section of this Notice below. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your dental health care or with payment for your dental health care, but only if you agree that we may do so. We will disclose only the health information that is relevant to the person's involvement. 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 health care. 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. We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as during a medical emergency or disaster relief efforts.

Marketing Services: We will not use your health information for marketing communications without your verbal or written authorization.

Required by Law: We may use or disclose your dental health information when we are required to do so by law for health and benefit activities for public health including to avert a serious and imminent threat to health or safety; for health care oversight (such as activities of state insurance commissioners, licensing and peer review authorities, and fraud prevention agencies); for research; in response to court and administrative orders and other lawful process; to law enforcement officials with regard to crime victims and criminal activities; and to coroners, medical examiners, funeral directors, and organ procurements organizations. If a use or disclosure of health information described above in this Notice is prohibited or materially limited by other laws that apply to this practice, it is our intent to meet the requirements of the more stringent 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 requested dental health information to correctional institutions or law enforcement officials having lawful custody of an inmate receiving treatment.

Health-Related Products and Services: We may use your medical information to communicate with you about health-related products, benefits, services, payment for those products and services, and treatment alternatives.

Appointment Reminders: We may use or disclose your dental health information to provide you with appointment reminders.


Access: You have the right to examine or receive copies of your health information, with limited exceptions. You may request that we provide copies in a certain format unless we cannot practicably do so. To obtain access to your health information, you must submit a request in writing to our Privacy Officer.

Disclosure Accounting: You have the right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request. 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.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. Except in limited circumstances, we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in a medical emergency or as required or authorized by law.

Alternative Communication: You have the right to request that we communicate with you in confidence about your health information by alternative means or to alternative locations. You should make your request in writing and submit it to our Privacy Officer. 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 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. If we deny your request, we will provide you a verbal or written explanation, and you may have a statement of your disagreement added to your dental information. If we accept your request, we will make your amendment part of your health information record and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.

Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Breach notification may be delayed if so required by a law enforcement official.

Electronic Notice:  As you read and receive this Notice on our website or by electronic mail (e-mail), know that you are also entitled to receive this Notice in written form by making a request of our Privacy Officer.


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, a request 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 contact our Privacy Officer. You also may submit a written complaint to the Office for Civil Rights of the U.S. Department of Health and Human Services at 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for Civil Rights Hotline at: 1-800-368-1019.

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.


Written requests should be mailed to the attention of the Privacy Officer at: 6008 N. State Route 9, Suite C, Parkville, Missouri 64152

Our Privacy Officer is Office Manager Jamie Casey.  You may call at: 816-741-5480; or fax your concerns to: 816-741-6812 or email: escjamie@kc.rr.com