New to Pearl Dental?
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New Patient Forms
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To make your visit as painless as possible, these registration forms should be filled out completely prior to your first visit. They will detail all of the information we need to establish you as a patient and put you into our database. Since Pearl Dental is a family dentistry practice, we will require a new patient intake form for any children you bring to see us as well.
New Patient Intake Form Financial Agreement Consent For Use Health Information Disclosure Dental Records Release Form If you are unable to open PDF files, you can get Adobe Reader for free HERE. |
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Office Hours
Pearl Dental is open Monday through Thursday, 8:00 a.m. to 5:00 p.m.
Your First Visit
Your very first visit will last approximately one hour. The purpose is for us to gather information about you, so we can give you the best care possible. After your new patient paperwork is finished, you will see one of our doctors. They will proceed with a full comprehensive exam, address any concerns you may have and give you available options for your treatment plan. X-rays are taken at this visit also, unless we are able to obtain them from your previous dentist. If this is the case, please fill out a release form and return to our office before your scheduled appointment.
What To Bring
If you haven't emailed your new patient paperwork back to us, please bring it with to your first appointment. Even though your form will completely list all of your insurance information, we ask that you please bring your insurance card and driver's license with you so that we may verify coverage for you and any dependents. Also bring a complete list of any medications you are taking, along with dosages. Any changes to address, phone number or insurance we ask that you notify us prior to your scheduled appointment.
Scheduling An Appointment
We make every effort to be on time for our patients and ask that you extend the same courtesy to us. If you cannot keep an appointment, please notify us as soon as possible. If you have to reschedule, know that most of our appointments are made 4-8 weeks in advance. If you are in pain or have an emergency situation, every attempt will be made to see you as soon as possible.
Refer A Friend
Once you know about the great care here at Pearl Dental you can spread the word! If you refer a new patient to us, not only will they receive a $50 credit on their account, but you will also!
Please understand that you, the patient, are fully responsible for all fees incurred by our office regardless of your insurance coverage. Payment will be due at the time of service.
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For your convenience we accept Visa, MasterCard, Discover, American Express and CareCredit. You may also pay with cash or check. If there is a remaining balance after your insurance company sends payment to our office, we will send you a statement payable within 14 days. If you have any questions regarding your account, please don't hesitate to give us a call at (320) 654-9999. |
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Insurance and Financing
At Pearl Dental, we strive to make every effort to make your visit as painless as possible, that includes your insurance coverage!
We are in network with multiple insurance companies and want to help you maximize your insurance reimbursement for your
covered procedures.
Please bring your insurance card with you to your next appointment so we can expedite your reimbursement. Should you have any questions regarding if Pearl Dental is in your network, there is a phone number for your insurance company on the back of your card, or feel free to call our office at 320-654-9999 and a member of our team will be happy to assist you.
We are in network with multiple insurance companies and want to help you maximize your insurance reimbursement for your
covered procedures.
Please bring your insurance card with you to your next appointment so we can expedite your reimbursement. Should you have any questions regarding if Pearl Dental is in your network, there is a phone number for your insurance company on the back of your card, or feel free to call our office at 320-654-9999 and a member of our team will be happy to assist you.
Pearl Dental accepts cash, check, credit cards and offer flexible financing and payment options through CareCredit. We also accept most insurance plans and are happy to help you maximize your benefits.
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Click on the logo of your insurance company for more information
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No insurance? |
Have questions about your insurance?
We can help you understand your benefits and file insurance forms on your behalf.
We can help you understand your benefits and file insurance forms on your behalf.
Pearl Dental Privacy Policy
Our Legal Duty: We are required by law to maintain the privacy of protected health information and provide notice of our legal duties and privacy practices. We are required to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices described in this notice white it remains in effect. We reserve the right to change our privacy practices and terms of this notice at anytime, provided the changes are applicable by law. We will make provisions and post the new notice immediately here on our website and it will be posted at our office. Copies of the new notice will be provided upon request.
How we may use and disclose health information about you.
Treatment: We may disclose your health information to a specialist that we have referred you to for treatment. Oral Surgeons, Endodontists, Periodontists and Periodontists are just a few examples.
Payment: We may use your health information to obtain reimbursement for services you receive from us. Payment activities include determining eligibility and coverage from an insurance company or another third party. Sending claims to your health plan, claims management, pre-determinations, billing and collections are all areas where they would use your information to identify you.
Individuals involved in your care or payment for your care: We may disclose your health information to family, friends or any individual identified by you when they are involved with your care or payment for your care. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.
Required by law: We may use or disclose your health information, when required by law.
Public Health Activities: We may disclose your health information to public activities to:
National Security: We may disclose health information of Armed Forces personnel to military authorities. We may disclose to authorized, federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of an inmate or patient.
Secretary of HHS: We will disclose your health information to the Secretary of the United States Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker's Compensation: We may disclose your information necessary to comply with laws relating to worker's compensation or other similar programs established by law.
Law Enforcement: We will provide your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Health Oversights Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and credentialing as necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. Also due to a response to a subpoena, discovery request or other lawful process instituted by someone else involved in the dispute but only if efforts have been made by the requesting party or us to tell you about the request.
Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has examined the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner when necessary to identify a deceased person or determine the cause of death. We may disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
Fundraising: We may contact you to provide you with information about our sponsored activities, including fundraising programs as permitted by law. If you do not wish to receive such information, you may opt out of receiving these communications.
Your Health Information Rights
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing or obtain a form from our office to request access or forwarding of your records to another dental facility. If you request information that we maintain on paper, we may provide photo copies. Electronic records, you have the right to an electronic copy.
Disclosure Accounting: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information. To request an accounting of disclosures of your health information, you must submit the request in writing to our office.
Right to Request a Restriction: You have the right to request additional restrictions on our use of disclosure of our PHI by submitting a written request to our office. Your written request must include what information you want to limit and whether you want o limit our use, disclosure or both and whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of payment and the information pertains to a service for which you or another person on your behalf has paid our practice in full.
Alternative Communication: You have the right to request to receive confidential communications from the practice by alternative means or at an alternate location. You must submit a written request specifying the alternate means and location and provide a satisfactory explanation of how payments will be handled under the alternative means you requested. If we are unable to contact you using the alternate ways, then we may contact you using the information we have.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and must explain why the information should be amended. We may deny your request under certain circumstances.
Right to Notification of a Breach: You will receive notification of a breach of your unsecured protected health information as required by law. If you believe your privacy rights have been violated, you have the right to complain to the dental practice or you may submit a written complaint to the U.S. Department of Health and Human Services.
How we may use and disclose health information about you.
Treatment: We may disclose your health information to a specialist that we have referred you to for treatment. Oral Surgeons, Endodontists, Periodontists and Periodontists are just a few examples.
Payment: We may use your health information to obtain reimbursement for services you receive from us. Payment activities include determining eligibility and coverage from an insurance company or another third party. Sending claims to your health plan, claims management, pre-determinations, billing and collections are all areas where they would use your information to identify you.
Individuals involved in your care or payment for your care: We may disclose your health information to family, friends or any individual identified by you when they are involved with your care or payment for your care. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.
Required by law: We may use or disclose your health information, when required by law.
Public Health Activities: We may disclose your health information to public activities to:
- Prevent or control disease, injury or disability.
- Report child abuse or neglect.
- Report reactions to medications or problems with products or devices.
- Notify a person of a recall, repair, or replacement of products or devices.
- Notify a person who may have been exposed to a disease or condition.
- Notify the appropriate government authority if we believe the patient has been a victim of abuse, neglect or domestic violence.
National Security: We may disclose health information of Armed Forces personnel to military authorities. We may disclose to authorized, federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of an inmate or patient.
Secretary of HHS: We will disclose your health information to the Secretary of the United States Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker's Compensation: We may disclose your information necessary to comply with laws relating to worker's compensation or other similar programs established by law.
Law Enforcement: We will provide your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Health Oversights Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and credentialing as necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. Also due to a response to a subpoena, discovery request or other lawful process instituted by someone else involved in the dispute but only if efforts have been made by the requesting party or us to tell you about the request.
Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has examined the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner when necessary to identify a deceased person or determine the cause of death. We may disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
Fundraising: We may contact you to provide you with information about our sponsored activities, including fundraising programs as permitted by law. If you do not wish to receive such information, you may opt out of receiving these communications.
Your Health Information Rights
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing or obtain a form from our office to request access or forwarding of your records to another dental facility. If you request information that we maintain on paper, we may provide photo copies. Electronic records, you have the right to an electronic copy.
Disclosure Accounting: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information. To request an accounting of disclosures of your health information, you must submit the request in writing to our office.
Right to Request a Restriction: You have the right to request additional restrictions on our use of disclosure of our PHI by submitting a written request to our office. Your written request must include what information you want to limit and whether you want o limit our use, disclosure or both and whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of payment and the information pertains to a service for which you or another person on your behalf has paid our practice in full.
Alternative Communication: You have the right to request to receive confidential communications from the practice by alternative means or at an alternate location. You must submit a written request specifying the alternate means and location and provide a satisfactory explanation of how payments will be handled under the alternative means you requested. If we are unable to contact you using the alternate ways, then we may contact you using the information we have.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and must explain why the information should be amended. We may deny your request under certain circumstances.
Right to Notification of a Breach: You will receive notification of a breach of your unsecured protected health information as required by law. If you believe your privacy rights have been violated, you have the right to complain to the dental practice or you may submit a written complaint to the U.S. Department of Health and Human Services.
What Our Patients Have To Say...
