Online Application For Smiles Change Lives

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment: Your protected health information may be used by staff members, volunteers, agents and national and advisory board members of the Virginia Brown Community Orthodontic Partnership d/b/a Smiles Change Lives and disclosed to other health care professionals, including but not limited to your assigned screening and treatment provider(s), for the purpose of evaluating your application and providing your treatment.

Program Operations: Patient information, including first name, case history and photographic images may be used as necessary to support assessment, public relations, fund development and other activities of Smiles Change Lives.

Law enforcement: Your protected health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public health reporting: Your protected health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization: Disclosure of your protected health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you noticed us of your decision to revoke your authorization.

Individual Rights: You have certain rights under the federal privacy standards. These include: The right to get an electronic or paper copy of your record ▪ The right to request confidential communications ▪ The right to request restrictions on the use and disclosure of your protected health information ▪ The right to inspect and copy your protected health information ▪ The right to amend or submit corrections to your protected health information ▪ The right to receive an accounting of how and to whom your protected health information has been disclosed ▪ The right to receive a printed copy of this notice ▪ The right to file a complaint.

Smiles Change Lives Duties: We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice and to notify you when a breach of your unsecured protected health information has occurred.

Right to Revise Privacy Practices: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice. The revised policies and practices will be applied to all protected health information we maintain.

Request to Inspect Protected Health Information: You may generally inspect or copy the protected health information we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting SCL at the address below.

Complaints Contact Person: If you would like to submit a complaint or have questions regarding our privacy practices, you may contact us in writing at the following address: Smiles Change Lives, 2405 Grand Blvd, Suite 300, Kansas City, MO 64108, or you may also contact the Secretary of Health and Human Services. You will not be penalized or otherwise retaliated against for filing a complaint.

Effective Date: This notice is effective on or after 05/01/2005.

Smiles Change Lives (SCL) is happy to provide this once-in-a-lifetime opportunity for your child to receive braces – it is an opportunity that many children do not receive. However, we will only provide treatment if you and your child fully cooperate with the treatment provider and his/her treatment plan. All of the following conditions must be met to be eligible to start treatment and to continue treatment.

PARENT/GUARDIAN: PLEASE READ CAREFULLY

1. SCL provides for orthodontic treatment ONLY. Extractions, cleanings, oral surgery or other treatment that may be necessary before, during or after orthodontic treatment are the financial responsibility of the participant’s parents or legal guardians.

2. To be a part of this program your child must have good oral hygiene and not have any unfilled cavities. If your child has unfilled cavities or periodontal disease, these conditions must be completely remedied before treatment is started. Your child must have regular dental cleanings every six months during treatment. During the course of treatment, if your child’s teeth are not cleaned properly, cavities can form around the braces. Your child may be removed from the program at any time due to poor oral hygiene.

3. Treatment providers are limited in some areas and SCL cannot make guarantees of placement with a provider even if your child qualifies for the program. Waiting periods vary and can be longer than twelve (12) months based on area demand. During this time, you may be required to submit updated documents, including a 1040/SSI letter to ensure your child still qualifies for the program. Due to the high number of applicants and limited treatment spots open, SCL may search up to a 100 mile radius when assigning your child. If a provider is located, the parents/guardians agree to submit the nonrefundable $600 (USD) required financial investment upon notice from SCL. If payment is not received within 30 days of such notice, your child will lose his/her place in the program. SCL makes all provider assignments at its sole discretion and you agree to receive treatment from the provider assigned. If a treatment provider has not been assigned BEFORE your child turns 19, he/she will be removed from the program and will no longer be eligible for treatment. Note: we cannot accept payments from Flexible Spending Accounts or Health Savings Accounts.

4. Once accepted and the $600 is received, your child will begin treatment with the assigned SCL treatment provider. Treatment is only available from the assigned provider, who is donating his/her time and all materials/supplies required to provide full treatment for your child. Typically, the average cost of braces NOT acquired via Smiles Change Lives is $6,000. Note: once the $600 payment is received, it is non-refundable and will not be returned if your child is removed from the program in accordance with the program rules and guidelines.

5. Regular appointments are required to make sure teeth move as expected. Since the treatment provider is donating treatment, s/he may require you to attend appointments during non-peak hours. As a result, your child’s appointments will likely be scheduled during the mid-morning or mid-afternoon hours. It is your responsibility to make sure that all scheduled appointments are kept. If you must cancel or reschedule an appointment, you are required to give your doctor at least 24 hours notice. Not calling to cancel or missing an appointment is grounds to remove your child from the program and have your child’s braces removed.

6. You and your child must fully follow the treatment plan set by your treatment provider, which will be explained to you before treatment starts. If you fail to follow the treatment plan, including but not limited to proper use of bands, appliances, and retainers, the treatment provider has the option to refuse to continue treatment and to remove braces.

7. If you move before treatment concludes, please call us in addition to telling your treatment provider. You will be removed from the program and will be responsible for making arrangements to complete your child’s care. You may either have your SCL treatment provider remove the braces or you may locate a new treatment provider in your new community for which you will be financially responsible. SCL is not responsible for locating a new treatment provider or paying for continued treatment.

8. Providers donate their services based upon your child’s qualification for the SCL program, both in terms of orthodontic and financial need. As such, it is important that you treat the provider and his/her staff with respect, express your gratitude for their services and behave in a way that reflects positively on both SCL and your family at all times.

9. Your child may be removed from the program at any time (this includes during the application process, before assignment to a provider and after treatment has started) if the child or parent/guardian is uncooperative or disrespectful to SCL staff or the provider and his/her staff, or fails to comply with any SCL rules and guidelines. During the course of treatment, the provider may, at his/her discretion, refuse to continue treatment and may remove the child’s braces. If removed for cause, your child is no longer eligible to reapply to the SCL program.

10. Broken appliances or loose brackets and bands can cause damage to teeth and the rest of the mouth. Your child must not eat hard or sticky foods or pull on the braces. If there is frequent damage to the braces, the treatment provider has the option of removing the braces or charging you to repair the damage, which is not covered by this program.

11. One (1) retainer device will be provided as part of the treatment program at no charge. If this retainer is lost or damaged, you will be charged for a replacement.

12. If your child is accepted into the program, you consent to SCL’s use, without charge, of all photos, video or audio recordings of you and your child. SCL may (1) copyright, broadcast, display, publish, re-publish, and reproduce you and your child’s image, voice and any statements made by you and him/her, in whole or in part, in any and all media forms; and (2) assign you and your child a fictitious name or use your or his/her first name, likeness, video, photograph, voice, statements and biographic or other information concerning his/her participation with SCL, for fundraising or other promotional and advertising purposes. You and your child agree to participate in surveys and case management during and after treatment.

13. SCL coordinates all communication between families/children and the treatment providers. Do NOT contact a provider unless instructed by SCL. If you contact a provider without permission, your child may be removed from the program.

The undersigned has read, understands and agrees to abide by the attached Program Rules and Guidelines, which are incorporated herein by reference, for receiving orthodontic treatment through the Virginia Brown Community Orthodontic Partnership d/b/a Smiles Change Lives, and has been given the opportunity to ask questions about this information.

If our application is approved and a treatment provider is located, I consent to allow Smiles Change Lives and its partner doctors to provide orthodontic treatment for my child. I understand that acceptance into the Smiles Change Lives program for my child’s orthodontic care is based on our (my child’s and my) ability to maintain my child’s oral health as indicated in the Program Rules and Guidelines and to abide by all the Program Rules and Guidelines.

I also understand that if we do not maintain oral hygiene and abide by the Program Rules and Guidelines, my child will be removed from the program, his/her braces will be removed and treatment will be terminated with no refund of the $600 payment. I further agree that if treatment is stopped early and my child is removed from the program for not following the Rules and Guidelines, or for any other reason, we (my child and I) will hold Smiles Change Lives and the assigned treatment provider harmless and free from any liability for any damage or injury resulting from the termination of said treatment.

I, on behalf of myself and my child, acknowledge that Smiles Change Lives does not itself provide the orthodontic treatment and that all treatment will be provided by a doctor assigned by Smiles Change Lives (“partner doctor”). I expressly authorize Smiles Change Lives, the partner doctor(s) and my dentist (as listed on my Dental Referral Form) to share my child’s medical records and information with each other in order to coordinate and manage my child’s treatment. In consideration of the acceptance of my child’s application by Smiles Change Lives, we (my child and I) release Smiles Change Lives and the partner doctor and their agents, employees, board members, officers, representatives, and successors and assigns from any and all claims, demands, actions, proceedings, damages or liability of any kind whatsoever that we may have at any time arising, directly or indirectly, from (i) our participation in the Smiles Change Lives program, or (ii) any action taken by Smiles Change Lives or the partner doctor based on the Program Rules and Guidelines, including but not limited to my child’s removal from the program and the removal of his/her braces. I further acknowledge and understand that Smiles Change Lives and the partner doctor do not guarantee satisfaction with the outcome of the orthodontic treatment provided. This Agreement shall be interpreted and enforced in accordance with the laws of Missouri and is intended to be as broad and inclusive as permitted by the laws thereof or of any other state where Smiles Change Lives program activities occur. Waiver of any provision by Smiles Change Lives shall not operate or be construed as a continuing waiver. This Agreement shall survive termination or completion of my child’s treatment. If any portion of this Agreement is held invalid, the remainder of it shall remain effective.

YOUR SIGNATURE INDICATES THAT YOU HAVE READ, UNDERSTAND AND VOLUNTARILY AGREE TO THE ABOVE CONSENT AND HOLD HARMLESS AGREEMENT.

Custodial Parent or Legal Guardian Consent: I further certify I am the custodial parent or legal guardian for the child named below, that I have legal authority to make medical decisions for the child, that all the information enclosed in this application is true and correct and that all income is reported. I understand that deliberate misrepresentation will not be tolerated and will result in permanent dismissal from the program.