I certify that I have read and understand these questions and that the information given is accurate. I understand the importance of a truthful health history and that my orthodontist and her staff will rely on this information for treating you. I will not hold my orthodontist or any other member of her staff responsible for any action they take or do not take because of the errors or omissions that I may have made in the completion of this form.
Your Information. Your Rights. Our Responsibilities. This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Example: We use health information about you to manage your treatment and services.
Example: We give information about you to your health insurance plan so it will pay for your services.
How Else Can We Use or Share Your Health Information?
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information purposes.
State-Specific Disclosure Restrictions
Pennsylvania Health Privacy Law
PA: We will not share any HIV-related, mental health, or substance abuse treatment records without your written permission, except as required by law. MD: We will only share medical records as required by the Maryland privacy laws.
Changes to the terms of this Notice
We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request in our office and on our website.
If you believe your privacy rights have been violated, contact our Practice Privacy Officer at: 888-333-3757
I have been given of McCormick Orthodontics Notice of Privacy Practices ("Notices"), which describes how my health information is used and shared. I understand that the Practice has the right right to change this Notice at any time. I may obtain a current copy by contacting the Practice Privacy Officer.
My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:
Type of Information: I authorize McCormick Orthodontics, and/or its duly authorized agents, to publish the following personal health information (Check the appropriate spaces and include other information where indicate).
PLEASE NOTE: Sensitive health information such as HIV/AIDS, sexually transmitted diseases, substance abuse treatment, mental health, and genetic information are NOT authorized.
Recipient of Information: The information may identify me by name and may be used in print media, on the radio, TV, the McCormick Orthodontics website, blog and on the following social media platforms: Facebook, Pinterest, Instagram, and Youtube.
Authorization Expiration: This authorization is valid from the date of my signature below and shall expire at the completion of treatment.
Authorization Statements/Signatures: I understand that any personal health information or other information released via the social media platform(s) listed above may be subject to re-disclosure by such social media platform(s) and the HIPAA Privacy Rule may no longer protect the information/
I understand that I have a right to revoke this authorization by providing written notice to McCormick Orthodontics; however, I understand that revocation will not apply to information that has already been released in response to this authorization.
I understand that signing this authorization form is voluntary, and I am not required to do so in order to receive healthcare treatment. I also understand that my refusal to sign will not affect my eligibility for benefits, enrollment, or payment for healthcare services. I further understand that I have a right to receive a copy of this authorization.
Informed Consent for the Orthodontic Patient-Risks And Limitations of Orthodontic Treatment
Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should seriously consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.
Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention, interception, and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.
An orthodontist is a dental specialist who has completed at least two additional years of graduate training in orthodontics at an accredited university after graduation from dental school.
Results of Treatment
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist’s instructions carefully.
Length of Treatment
The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth, and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond the original estimate, additional fees may be assessed.
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Nonprescription pain medication can be used during this adjustment period.
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non-removable retainers or other dental appliances made by your family dentist.
Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the procedure.
Some patients have significant skeletal disharmonies which require orthodontic treatment is conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with surgery which you should discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment.
Decalcification and Dental Caries
Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease, and/or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient often consumes sweetened beverages or foods.
The roots of some patient’s teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth throughout life with severely shortened roots. If root resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of appliances prior to the completion of orthodontic treatment.
A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.
Periodontal (Gum and Bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitor your periodontal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.
Injury from Orthodontic Appliances
Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. This can result in orthodontic appliances being inhaled or swallowed by the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when orthodontic appliances are removed. This problem may be more likely when esthetic (clear or tooth-colored) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.
Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes. Patients must remove the elastic force prior to removing the headgear from the mouth so that it does not spring back. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.
Temporomandibular (Jaw) Joint Dysfunction
Problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the Head or Face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.
Impacted, Ankylosed, Unerupted Teeth
Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone), or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circumstance and the overall importance of the involved tooth and may require extraction, surgical exposure, surgical transplantation, or prosthetic replacement.
You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine- tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby “flatting” surfaces in order to reduce the possibility of a relapse.
Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal result (for example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges, or periodontal therapy, may be indicated. You are encouraged to ask your orthodontist and family dentist about adjunctive care.
As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them in order to determine when and if the third molars need to be removed.
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discontinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.
General Health Problems
General health problems such as bone, blood, or endocrine disorders, and many prescription and non-prescription drugs can affect your orthodontic treatment. It is imperative that you inform your orthodontist of any changes in your general health status.
Use of Tobacco Products
Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.
If any of the complications mentioned do occur, a referral may be necessary to your family dentist or another dental or medical specialist for treatment. Fees for these services are not included in the cost for orthodontic treatment.
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the doctor and/or treatment coordinator and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize McCormick Orthodontics to provide the treatment. I also authorize McCormick Orthodontics to provide my healthcare information to my other health care providers. I understand that my treatment fee covers only treatment provided by McCormick Orthodontics and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.
Consent to Undergo Orthodontic Treatment
I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment, and to the doctor(s) and, where appropriate, staff providing orthodontic treatment described by the doctor(s) for the below individual. I fully understand all of the risks associated with the treatment.
Authorization for Release of Patient Information
I hereby authorize McCormick Orthodontics to provide other health care providers with information regarding the below individual’s orthodontic care as deemed appropriate. I understand that once released, the doctor(s) and staff has (have) no responsibility for any further release by the individual receiving this information.
Consent to Use of Records
I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examination, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals.
Thank you for choosing our office to provide your orthodontic needs. As a special service to you, we assist in filing of insurance claims so that you might receive the full benefit available from your insurance coverage. We permit you to use your orthodontic benefit to lower your portion of the cost of orthodontic treatment, rather than paying the full fee upfront and waiting for reimbursement for the insurance company. This allows you the financial freedom of paying only your part of the treatment fee while we accept direct payment from your insurance company. In reliving you of this financial burden, we allow ourselves to be vulnerable to the insurance company, therefore, we have set some guidelines and limitations which must be recognized and adhered to.
We cannot be held responsible for knowing all the peculiarities and requirements of all insurance companies we deal with. It is your responsibility to become familiar with your own policy. If there is a peculiarity about your insurance company of which you did not inform us, and it results in an underpayment of estimated benefits, we will not be held responsible and the unpaid amount will be applied to your portion of the bill.
Change in benefits, eligibility, or carrier
At any point in treatment, if you change jobs or become ineligible for orthodontic benefits, you must notify us immediately and we will average any remaining benefits originally anticipated into your monthly payments. At any point in treatment, if your employer changes insurance carriers you must notify us immediately. If the new policy does not have as much coverage or does not have orthodontic coverage, we will average any remaining benefits originally anticipated into your monthly payments.
Intentional or unintentional withholding of benefits
When benefits are assigned directly to this office, if the insurance company send a check to you in error, we will hold you responsible for an immediate and complete reimbursement. Should you receive a check from your insurance company, mail or bring it to this office. Any attempt to withhold insurance funds received by you in error will result in an immediate terminations of this insurance agreement and we will hold you directly responsible for the balance of the payments due.
I certify that I am/my dependent is covered by dental insurance and assign directly to Michaela M McCormick DMD, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
McCormick Orthodontics may use my/my child’s health care information and may disclose such information to the insurance company and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed.