ROBERT A. KLEMENT, DDS

Hello!

We would like to welcome you once again to our dental practice and explain a little about our office policiesand goals. We believe in the theories of Modern Dental Care, which do not support the old premise of "When ithurts - fix it." Through proper preventative care and regular checkups, we believe that it is highly likely thatmost of our patients can expect to keep all of their teeth for all of their lives.

Our patients can expect from us:

1. A high degree of professional skill and ability.2. Dedication to your oral health care.

3. The highest effort to make your visits as comfortable as possible.4. The right treatment at the right time.5. Fees that are fair andiust for the services provided.

In return, we expect from our patients:

1. Cooperation in making and keeping appointments, with 24 - hour notice given forcancellations.

2. A conscientious effort toward good oral hygiene.3. Recall visits to maintain optimum oral health.4. Non-insurance balances paid at time of service. (See enclosed payment policy.). All accounts

are payable at time of service, unless other arrangements have been made.

5. Arrival 10 minutes prior to all scheduled appointment times, so that we may ask anyquestions we may have for you, check insurance, or update forms if needed.

In order for our newly formed relationship to be mutually satisfying and beneficial, we ask that at any time youhave a question or are unhappy about any treatment (proposed or performed), fee for service, or attitude of our

"Dental Team," you will discuss it with us promptly and openly. Misunderstandings and/or lack ofcommunication are the obstacles to our continued friendship and professional relationship.

If we have recommended treatment to correct any current conditions, please call our office to make an

appointment for a return visit at your earliest possible convenience.

Sincerely,

Robert A. Klement, D.D.S.

1310 River Run Drive . Wisconsin Rapids, W. 54494. TeL.7151421-3030 . Fax. 7151421-3161

ROBERT A. KLEMENT DDS1310 RIVER RLIN DRIVE

WISCONSIN RAPIDS, WI 54494(7ts) 421-3030

WISCONSIN CONSENT FORM

This form is to obtain an individual's written permission under Wisconsin law for our use and disclosure of thepatient's dental records to calry out: treatment, payment activities, and health care operations.

SECTION A: Individual Givine Consent

Name:

Patient Name: (if different than above)

Address:

Home Telephone: Work Telephone:

TO THE INDIVIDUAL: Please Read the Following and Complete the Information Requested.

Privacy Practices Notice: You have the right to read our Privacy Practices Notice before you decide whether to signthis consent. Our Notice provides a description of our treatment, payment activities, and health care operations, ofthe uses and disclosures we may make of your protected health information, and of other impoftant matters aboutyour protected health information. A copy of our Notice accompanies this consent. We encourage you to read itcarefully and completely before signing this consent.

SECTION B: The Uses and Disclosures Beins Authorized.

Our Use of Medical Information: By signing this form, you will consent to our use of your patient dental records tocalry out treatment, payment activities, and health care operations as set forth in our Notice of Privacy Practices.

Persons lnvolved in Care: By signing this form, you will consent to our use of your dental care records to thefollowing persons, including those involved in your care or payment for that care. Please list the person(s) youwould like involved in your care or payment for that care.

We may use professional judgement and our experience with common practice to make reasonable inferences of yourbest interest in allowing a person acting on your behalf to; pick up filled or written prescriptions, dental or medicalsupplies, x-rays, or other similar forms of protected health information.

ROBERT A. KLEMENT DDS13IO zuVERRLTN DRIVE

WISCONSIN RAPIDS, WI 54494(1ls) 421-3030

(page 2 of Wisconsin Consent Form)

Right to Revoke: This consent is effective until revoked by you. You may revoke this consent at any time by givingwritten notice of revocation to the Contact Office listed below. Revocation of this consent will not affect any actionwe took in reliance on this authorization before we received your written notice of revocation.

OFFICE NAME AND CONTACTS: Robert A. Klement DDS / Attention: Roxann

TELEPHONEz (715\ 421-3030 FAX: (715) 421-3161 E-MAIL:

ADDRESS: 1310 River Run Drive CITY/STATEIZIP CODE: Wisconsin Rapids. WI 54494

I, (please print)office of Robert A. Klement DDS, and

have received a copy ofthe Notice of Privacythe Wisconsin Consent Form. Please sign below.

./I, (please print) K , have had full opportunity to read and consider thecontentSofthisWisdo,'i',c@ysigningthisfoim,Iamconfirmingmywrittenpermission for the disclosure of the above named patient's protected health information, as described in this form.

Signature: K= nu,",

Relationship to Patient:(Please indicate ifsigned by a parent, legal guardian, or personal representative)

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices and the WisconsinConsent Form, but acknowledgement could not be obtained because:

L--g lndividual refused to sign the Wisconsin Consent Form!.

L-.e Communication barriers prohibited obtaining receipt of the Notice of Privacy Practices and the

Wisconsin Consent Form"!'(-9 An emergency situation prevented us from obtaining receipt of the Notice of Privacy Practices and the

Wisconsin Consent Form.tl-e 911r.. (please specifu)

Person responsible for account

Date of birth I I Soc. Sec. # Insured ID #(Employee) (Employee)

PATIENT (PRIMARY) DENTAL INSURANCE FORM

Patient Name

PRIMARY DENTAL INSURANCE

Name of policyholder

AddressCity Stqte Zip

(Employee)

Home phone ( )

Group #

Streel

lnsured person employed by Business phone L_-)lnsurance company name Phone L)lnsurance company address

Street City State Zip

ADDITIONAL (StrCONDARY) DENTAL INSURANCE

Is patient covered by another dental insurance? Yes

- No

- Name of policyholder

(Employee)

Date of birth I I Soc, Sec. # _-_ Insured ID # Group#(Employee) (Employee)

Address Home phone (___-)Street City State Zip

lnsured person employed by Business phone (__J

Insurance company name Phone t__)Insurance company address

Street City State Zip

AUTHOzuZATIONI authorize and request my insurance company to assign payment of all insurance benefits directly to the dentistor dental group otherwise payable to me for services rendered, I understand that I am financially responsiblefor payment in full of all dental services, regardless of insurance coverage. This signature will authortze allsubmission of dental claims and the rglease of necessary information for payment of dental services.

Signature

MEDICALIDEI{TAL HISTORY

Patient Name

Address

State ZipPhone ( )Physician

Guardian/Parent Name(If patient is a child)

,/Person Responsible For Account L

Are you under the care ofa physician?Yes No

Are you taking any medications, prescription ornon-prescription? (I.E. : Birth control, bloodthinner, Aspirin, etc?)

Yes NoPlease list

Are you pregnant?Yes No Due date

Have you had any allergic reaction to any medications,local anesthetic, or Nitrous Oxide? Other allergies?

Yes No Please list

Have you ever taken a medication to increase bone density ?

Yes No Please list

(Example: Fosamax, Boniva, Actonel, Reclast etc.)

Do you require antibiotic premedication for dental treatment?Yes No

Have you ever taken Fen-Phen for dieting?Yes No

Have you ever been treated for alcohol or substance abuse?Yes No When?

Have you ever had radiation treatment or chemotherapy?Yes No When?

Date of Birth Soc. Sec. # -

Home Phone (_-) Wk. Phone C_-)

Cell Phone (_-)

Patient (Parent) Employed By

Name of Spouse

Spouse (Parent) Employed By

Do you now have, or ever had:(Please indicate)

_ Heart Murmur_ Heart Attack

_ Stroke

_ High Blood Pressure

_ Low Blood Pressure

_ ArthritisCongestive Heart FailureHeart surgery Q.E.: Bypass, open heart surgery,

_ Pacemaker)AsthmaMitral Valve ProlapseCongenital Heart DefectRheumatic Fever or Rheumatic Heart Disease

_ Diabetes

_ Any other heaft ailment?

_ Synthetic replacements or transplants-(I.E.: hip, knee, etc.)

_ EmphysemaRheumatism

_ Active Hepatitis

_ Tuberculosis

_ Venereal DiseaseHerpes

_ Are you HIV positive

_ Bleeding or clotting problems

_ Blood Disease (LE.: Leukemia or Acute and Chronic

_ Anemia)

_ Significant visual difficulties_ Significant hearing loss

_ Respiratory Disease

_ Muscular disease or disorder of the nervous system-(I.E.: MS, Epilepsy, etc.)

_ Emotional or nervous problemsHistory of fainting

Last First MI

Street City

Patient Signature Is there anything else we should know?(Patient li years opersonal representative)

Date X

Are you having any discomfort at this time?Yes No

Please describe

Are any of your teeth sensitive to:HeatColdSweetsPressure when biting

Have you ever had braces or orthodontic appliances?Yes No

Have you ever had any trauma to your teeth?Yes No When?

Do you frequently drink liquids with sugar?Yes No

Does food wedge between teeth?Yes No Where?

Do you grind or clench your teeth?Yes No

Do you have pain in and around your ears or jaw?Yes No

Do you have frequent headaches?Yes No

Do you hear clicking or popping noises when you openor close your mouth?

Yes No

Do you smoke or chew tobacco?Yes No

How do you feel about the look of your teeth and smile?Good Fair Poor

Are you interested in hearing about the options that you haveto improve your smile?

Yes No

Whom can we thank for referring you?

How often do you brush?

How often do vou floss?

Do you have bleeding gums?Yes No

Have you ever had periodontal surgery (gum surgery)?Yes No When?

Do you often feel you have bad breath?Yes No

Do you have a bad taste in your mouth at times?Yes No

If you are a new patient, when was your last dental cleaning?

For children. in the absence ofa oarent or guardian:

Do we have your permission to apply a fluoride treatment on your child?Yes No

Do we have your permission to take x-rays, if needed, on your child for his or her dental care?Yes No

Parent's Signature Date(Parent, legal guardian, or personal representative l8 yearsor older)

For the o Robert A. I{Ie nt. DDS.

Financial and Puvment PolicY

Our financial/payment policy stqtes thut we must.recelfe payment

for non-insurance balance at the time the service is rendered, Listedbelow ,sre the options available to choose from. Thank you,

{iru iln ci aW av ment OP tions i

l, We qffer a 5% disoount (ifpaid b)r oash or.check) for payment in Jul!on vour t balance with the followi idelines:

o Payrnent must be reeeive-d at the time services arerendered. This applies tq each sg.hedrlledappointment.

. Our discounf applies onty to non-insurance balancesexceeding $350.00

2, Appl-.2 the fpll'balance.to your personal crgdit card. We acqept Delitisa. and Mas iscount of aonlv to credit card

Apply full balance to.soine other form of oujside finalrcin&

Any other financial.?rrangernents must be rnade and aqreed upQ!with Dr, Klernefrt or a staff menlber Prior,lo an)a scheduledappointrnents.

3,

4,

Please contact our office ai (715) 421-3030, so we may make these

Jinanc.ial arrungem.enls., schedule qny necesssry sppointments to rendeitreatment, or if you have any questions. Thunk you,

ROBERT A. KLEMENT DDS1310 RIVER RUN DRIVE

WISCONSIN MPIDS, WI 54494(71s\ 421_3030

NOTICE OF PRIVACY PRAGTICESTHIS 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 tS IMPORTANT TO US.

OUR LEGAL DUTYWe are required by applicable federal and state law to maintain the privacy of your health information. We are also required togive you this Notice about our privacy practices, our legal duties, and your righis concerning your health information. We mustfollow the privacy practices that are described in this Notice while it is in effect. This Noticelikes effect (04114t03), and willremain 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 arepermitted by applicable law. We reserve the right to make the changes in our privacy fractices and the new terms of ourNotice effective for all health information that we maintain, including health information w-e created or received before we madethe changes. Before we make a significant change in our privacy practices, we will change this Notice and make the newNotice available upon request.

Y9u.1ay request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies ofthis Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATIONWe 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 toyou.

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 ofhealthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation,certification, licensing or credentialing activities.

Your Authorization: ln addition to our use of your health information for treatment, payment or healthcare operations, youmay give us written authorization to use your health information or to disclose it to anyone for any purpose. lf you give us anauthorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures peimitteO by yourauthorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your healthinformation 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 ofthis Notice. We may disclose your health information to a family member, friend or other person to the extent neCessary to helpwith your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons lnvolved ln 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 yoJrlocation, your general condition, or death. lf you are present, then prior to use or disclosure of your health information, we willprovide you with an opportunity to object to such uses or disclosures. ln the event of your incapacity or emergencycircumstances, we will disclose health information based on a determination using our professional judgmeni disclosing onlyhealth information that is directly relevant to the person's involvement in your healthcare. We will also use our professionaljudgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person topick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

ROBERT A. KLEMENT DDS1310 RIVER RUN DRIVE

WISCONSIN RAPIDS, WI 54494(715) 421-3030

(page 2 Notice of Privacy Practices)

Marketing Health-Related Services: We will not use your health information for marketing communications without yourwritten 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 apossible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your healthinformation 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 certaincircumstances. We may disclose to authorized federal officials health information required for lawful intelligence,counterintelligence, and other national security activities. We may disclose io correctional institution or law enforcement officialhaving laMul custody of protected health information of inmate 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, e-mail, postcards, or letters).

PATIENTS RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request thatwe 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. Please notify us by using the contactinformation listed at the end of this Notice to receive a form. lf you request copies, there will be fees that will apply.

(1) For records displayed on paper medium, the greater of the following:(a) $4.+O per request, or(b) .45 cents per record page for the first 50 pages, and .25 cents per record page over 50 pages

(2) $+.OO per x-ray copy

(3) The actual costs of postage, or other means of delivering the requested duplicate records

(4) These fees may increase in the future at the discretion of this office.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosedyour health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the

iast 6 years, but not before April 14,2003. lf you request this accounting more than once in a 12-month period, we may chargeyou 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 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.

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: lf you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this

Notice in written form.

ROBERT A. KLEMENT DDS1310 RIVER RUN DRIVE

WISCONSIN MPIDS, WI 54494(715) 421-3C3,A

WISCONSIN ADDENDUMTO

NOTICE OF PRIVACY PRACTIGES

THIS ADDENDUM TO THE NOTICE OF PRIVACY PMCTICES SETS FORTH WISCONSIN PRIVACY REQUIREMENTSTHATARE IN ADDITION TO THOSE IN OUR NOTICE OF PRIVACY PMCTICES.

PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

WE ARE REQUIRED BY WISCONSIN LAW TO MAINTAIN THE PRIVACY OF YOUR HEALTH INFORMATION.

USES AND DISCLOSURES OF HEALTH INFORMATION

Healthcare Operations: Under Wisconsin law, we must have your written permission before we may use and disclose yourhealth information in connection with healthcare operations other than management of our medical records and certain auditingand review activities by staff committees and review organizations.

To Your Family and Friends and Persons lnvolved in Your Gare: Under Wisconsin law, we must have your writtenpermission before we may disclose your health information, other than limited identifying information, to your family, friends, orother persons involved in your care.

Abuse or Neglect: Under Wisconsin law, we must have your written permission before we may disclose your healthinformation to the appropriate authorities if we believe you are the victim of domestic violence or other crimes. We may reportchild abuse and the abuse or neglect of a vulnerable adult as allowed by Wisconsin law.

PATIENT RIGHTS

Restriction: While we are allowed to determine whether we agree to your request to restrict our use and disclosure of yourprotected health information, Wisconsin law requires that we honor certain restriction requests by private pay patients relatingto research or the release of information to government agencies.

QUEST]ONS AND COMPLAINTS

lf you want more information about our privacy practices or have questions or concerns, please contact us.

lf you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access toyour health information or in response to a request you made to amend or restrict the use or disclosure of your healthinformation or to have us communicate with you by alternative means or at alternative locations, you may complain to us usingthe contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department ofHealth and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Healthand 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 complaintwith us or with the U.S. Department of Health and Human Services.

OFFICE NAME AND CONTACTS: Robert A. Klement DDS / Attn: Roxann

TELEPHONE: (715\ 421-3030 FlnC ff15) 421-3161 E-MAIL:

ADDRESS: 1310 River Run Drive CITY/STATE/ZIP CODE: Wisconsin Raoids. Wl 54494