So, what`s inside?

JANUARY 2015 | VOLUME III | ISSUE 5
Art Students Recognized for Their Talents
Congratulations to the following Timberland High School
So, what’s inside?
artists for winning awards for their pieces at the Young
Upcoming Events ................ 02
Artists and Their Teachers 2014 Exhibit (YATTE) at
Tutoring ....................................... 02
Lindenwood in the J. Scheidegger Center for the Arts:
ACT Dates ................................ 02
Jace Garcia
Principal’s Note .................... 03
1st Place, Photography
2nd Place, Computer Arts
Abigail Preckel
2nd Place, Painting
Mckayla Oakley
3rd Place, Sculpture
The students are taught by Timberland Art Teacher and
Department Chair Crystal Wing.
The exhibit, which ran through December 7th, showcased
the best artwork created in the greater St. Louis region by
high school students and their art teachers.
2015-2016 Registration.... 03
8th Grade Orientation..... 04
Local Scholarship Drive... 04
A+ Training ............................... 04
Sail Into Senior Year ........... 05
Yearbook Orders ................. 05
Dental Care ............................ 06
College Visits .......................... 06
Student Recognition ......... 07
School Closing Policy ....... 08
Dental Permission ................ 09
Timberland Times Newsletter designed by Megan Spotila
THS
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
UPCOMING
EVENTS
ATTENTION SENIORS:
JANUARY
13-16 Registration materials distributed to
students
13-29 2015-2016 Online Course
It is very important to continue post
secondary exploration for completing
applications to meet any deadlines
listed by the college(s) of your choice!
DON’T FALL BEHIND!
Registration
14
8th Grade Registration and
Orientation Meeting @7pm
15
Board of Education MeetingCentral Office @7pm
19
NO SCHOOL
AFTER-SCHOOL TUTORING
Martin Luther King, Jr. Day
20
29
AFTER-SCHOOL TUTORING
Timberland offers tutoring sessions for all students
NO SCHOOL
Professional Development Day
Monday through Thursday from 2:25pm to 3:25pm in the
2015-2016 Course Registration
library. Teachers supervise students until they are ready
closes
to leave the building.
FEBRUARY
If your student is riding home on the Activity Bus, he or
02
Late Start Grades 6-12
she must remain with the teacher until 3:20pm. To ride
03
Local Scholarship Drive begins
the Activity Bus, your student must sign up the day he or
02-07 Spirit Week
04
DECA Districts
she plans to stay after school before 11 a.m. in the
Activities Office. However, there is NO ACTIVITY BUS ON
FRIDAYS.
ACT TEST DATES
2015 | February 7
April 18
June 13
Sign up for the ACT here!
Timberland Times Newsletter designed by Megan Spotila
ACT WORKSHOPS
Science | Jan 13 + 15
Math | Jan 27 + 29
English | Feb 3 + 5
See the Timberland homepage
for future ACT workshop dates.
All workshops are 7:00-9:00 pm.
Students are asked to sign up in
the guidance office.
PAGE 2
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
FROM DR. HOVEN’S DESK...
With the second semester just starting it seems crazy, but
this is the time of the year that heavy planning for next
year already starts. Students will be selecting courses for
next year over the coming days. While we try to assist
students in making good, thoughtful choices, it does not
always happen like we hope it will. Being so early, it can
be difficult for students to put the proper amount of
thought and planning into their choices. Often students
just plan to adjust their schedules when we return next
August. Unfortunately, that is not always possible. Not only can course sections fill
up, but there are often other conflicts within students’ schedules. Finally, we
make staffing decisions for next year based heavily on student course requests.
Please work with your student to make thoughtful decisions for course selections.
We have a lot of great courses and great opportunities for students, and we
sincerely want to see students get into the courses they need and want to help
them prepare for their futures. Thank you for your help.
2015-2016 COURSE REGISTRATION
During the second week of January, Timberland students will begin
registering for next year's classes. Counselors will visit with classes the
week of January 12, at which time they will distribute the Course
Planning Guides and information pertaining to the online registration
process to every student. A link to the Course Planning Guide and all
information pertinent to registration will also be posted on the
Timberland Guidance & Counseling website. While the registration
portal is open, teachers will take the opportunity to discuss with
students class progression and recommendations. The registration
portal will open Tuesday, January 13 and close at midnight, Thursday,
January 29.
Timberland Times Newsletter designed by Megan Spotila
PAGE 3
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
A+ TRAINING INFO
The next A+ training session is Thursday, February
5 in room 163 from 2:30 pm to 3:30 pm. Students
must preregister in the Guidance office.
Students must attend one training session before
they begin tutoring. Future A+ trainings will be
held on March 5, April 9, and May 14. For more
information, refer to the Career Center Website.
PSAT RESULTS
For those students who took the PSAT
at Timberland in October, results
were returned to them the second
week in December. Click
herehttps://www.collegeboard.org/
psat-nmsqt/scores for more
assistance with interpretation of the
results.
LOCAL SCHOLARSHIP DRIVE
The local scholarship drive begins on
February 3 with all applications due
by March 14. These scholarships are
offered to college bound seniors by
area organizations and families. The
scholarships are awarded on Honors
Night, (May 8, 2014). Applications will
be available in the guidance
office.
For more scholarship
information, visit The College/
Career/A+ website.
TAKE A LOOK!
The “Get in 2 College”
handbook is now
available on the
“College and Career
Center” link on the
Timberland homepage.
Check it out!
8TH GRADE ORIENTATION
Eighth grade registration and
orientation will be held at 7 p.m.,
W e d n e s d ay , J an u ar y 1 4 , at
Timberland High School. Parents and
current eighth grade students within
the Timberland boundary are invited
to attend. A letter with complete
details has been mailed to the
homes of current Wentzville School
District eighth graders.
Briefly, at orientation, the students will
be introduced to school curriculum
and activities with the help of Link
Crew. At the same time, the
counselors will distribute and explain
to the parents in the theater, the
Course Planning Guide and the
online class registration process.
For the most up-to-date news at Timberland check out our website!
Timberland Times Newsletter designed by Megan Spotila
PAGE 4
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
AP HONOR ROLL
The Wentzville School District has been honored again by the College
Board with placement on the 5th Annual Advanced Placement (AP)
District Honor Roll. Wentzville is one of only eight districts to be recognized
this year in Missouri, the only district in the state to achieve this distinction
in each of the past five years, and one of only six school districts
nationwide to appear on the Honor Roll for five consecutive years. The
WSD was recognized for increasing the number of AP courses offered in
high school while also improving student performance on the AP tests.
Achieving both of these indicates that the District is successfully
identifying motivated, academically prepared students who will benefit
most from rigorous AP course work.
AP courses were offered for the first time in the District during the 2008-09
school year, and this year the WSD is offering 25 AP courses including
advanced AP Calculus. “We are always seeking ways to improve our
SAIL INTO SENIOR YEAR
“Sail Into Senior Year” is a college
planning presentation that will be
held on January 22 at 6:30 p.m. in
the Timberland library. The program
is geared for parents of juniors;
however, all parents are welcome
to attend. Information will be
shared about the college
application process, A+ Program,
financial aid, scholarships, and
much more. If you are interested,
please RSVP to
kerrystengel@wentzville.k12.mo.us
curriculum, and being recognized by the College Board for five
consecutive years is a testament to our long and steady increase in AP
offerings and student achievement,” said Wentzville Superintendent Dr.
Curtis Cain. “Student success is always our primary focus, and our
continuing efforts to increase rigor helps to ensure our students are
college and career ready when they graduate.”
Advanced Placement classes enable students to pursue college-level
studies while still in high school. Each AP course culminates in a rigorous
exam, providing academically prepared students with the opportunity to
earn college credit, advanced placement or both, which can potentially
save students and their families thousands of dollars in college tuition.
Since 2008 the WSD has significantly increased the number of students
enrolled in AP courses, and simultaneously increased the percentage of
students earning AP Exam scores of 3 (out of a possible 5) or higher. Many
U.S. colleges and universities grant college credit or advanced
YEARBOOKS
Order ONLINE or CALL
1-866-287-3096,
school code: 08123
Credit, Debit, and Checks only!
Before Dec. 3, yearbooks are $50.
After Dec. 3, yearbooks are $55.
Nameplates are available for an
additional $5.
Questions? Contact Ida Hoffman at
Idahoffmann@wentzville.k12.mo.us
placement for a score of 3 or above on AP exams.
Timberland Times Newsletter designed by Megan Spotila
PAGE 5
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
From the Nurse’s Office: Dental Care
Want your child to receive state-of-the-art dental services from a Missouri licensed dentist while at school? Keep
reading....
Did you know?



60% of school-age children (5-17 years) have dental cavities
Over 51 million school hours are lost each year due to poor dental health
Tooth decay is the single most common chronic childhood disease...5x more common than asthma.
Timberland is proudly hosting the "SMILES PROGRAM" Wednesday, February 4th, 2015.
The Smiles Program, started over 17 years ago, features local, caring, Missouri licensed dentists and hygienists who
come into the schools and provide both preventative, as well as restorative dental care to students who are either
covered under Medicaid or who have private dental insurance (most dental insurances accepted). For those
students without Medicaid or private
insurance and lacking sufficient funds,
Preventive Care Provided:
Restorative Care Provided:
the mobile dentists provide generous
 Complete dental exam
grant-assistance. NO CHILD IS EVER
 Fillings
 Screening
 Simple extractions
TURNED AWAY for lack of resources.
 Cleaning
 Pulpotomy (treatment of the
nerves inside baby teeth)
 X-Rays
Smiles Program employs the latest

Crowns

Fluoride
treatment
technology in portable equipment and
 Sealants
all services are OSHA and HIPAA
 Oral health instruction
compliant, and follow CDC sterilization
 Free toothbrush
guidelines.
For your child to participate, please fill out the parent permission form on page 9, or permission
slips can be picked up in the THS school nurse's office anytime Monday-Friday between
6:45am-3:15pm.
UPCOMING COLLEGE FIELD TRIPS
February 12, 2015 - St. Charles Community College field trip for seniors planning on
attending in the fall. Permission forms are available in the guidance office starting
January 5. This trip is open first to students who are completing the A+ Program and
then to other seniors as space allows.
February 27, 2015 - SCC Career Expo field trip to St. Charles Community College.
Open to juniors and seniors who would like to explore a wide range of career
areas. More information to come in January.
More information and permission forms are available in the guidance office.
Timberland Times Newsletter designed by Megan Spotila
PAGE 6
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
Memory Project
Timberland student artwork is currently on display at the Wentzville Public Library (Corporate Parkway Branch). The artwork
consists of drawings for the Memory Project. Students in Ms. Wing's Studio class, and students from Mr. Holland’s Painting class
are participating in the Memory Project and have work exhibited.
The Memory Project is a unique initiative in which art students create portraits for children and teens around the world who
have been neglected, orphaned, or disadvantaged. Given that kids in such situations
tend to have few personal keepsakes, we're aiming to provide them with special
memories that capture a piece of their childhood - portable pieces of their personal
history. As much as possible, we also want to help the kids see themselves as works of
art.
To do this, art students receive photos of kids on our waiting list and then work in any
medium to create the portraits (drawing, painting, digital art, collage, etc). Next, we
deliver the portraits to the kids as gifts. We also take photos of the kids holding the
portraits so the art students can see the delivery in action.
The majority of youth on our waiting list for portraits already have people taking care
of their basic needs of food, healthcare, education, etc. So we’re aiming to go
beyond the basic needs to touch the kids’ lives in a fun, artistic way.
However, we do also like to help financially support the children who receive our
portraits, so as much as possible we make monetary donations to the organizations
that are caring for them day in and day out.
To find out more visit http://memoryproject.org/questions.php.
COLLEGE COMMITMENTS
NCAA Division I
CJ Shaeffer
Storme Cooper
Ian Nelson
Dustin Gray
Patrick Kunza
Baseball
Baseball
Baseball
Wrestling
Track & Field
Western Kentucky University
Southern Mississippi University
University of Missouri
West Virginia University
University of Missouri
NCAA Division II
Tanner Forck
Angel Badalamenti
Chance Cooper
Olivia Beseda
Baseball
Softball
Wrestling
Cheer leading
Truman State University
Missouri Southern State University
McKendree University
Lindenwood University
NAIA
Payton Guffey
Cheerleading
Avila University
JUCO
Nic Gauspohl
Deja Lundberg
Baseball
Soccer
Meramec Community College
St. Charles Community College
Timberland Times Newsletter designed by Megan Spotila
PAGE 7
T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S • T I M B E R LAN D T I M E S
WSD INCLEMENT WEATHER/SCHOOL CLOSING POLICY
Timely communication with our district families is always a priority, and especially important in
emergency school closing situations. If WSD schools are forced to close due to inclement
weather or other factors (i.e. power outages, water main breaks) parents/guardians and
students will be notified in the following ways.
DISTRICT PHONE CALL/TEXT
The
Wentzville
utilizes
When inclement weather causes the district to
broadcasting
cancel school or dismiss classes early, please
system that allows school administrators to
check the following television and radio stations
notify all households by phone within minutes
for school closing information:
of an emergency or unplanned event that
KTVI - TV Channel 2
KMOX Radio 1120 AM
KMOV - TV Channel 4
KWRE Radio 730 AM
individual schools to communicate general
KSDK - TV Channel 5
KFAV Radio 99.9 FM
announcements or reminders. In case of any
These TV and radio stations also have websites
SchoolReach,
School
a
District
TV/RADIO
telephone
causes early dismissal or school cancellation.
The service may also be used occasionally by
changes in personal contact information, for
these reasons, it is extremely important that
you notify school offices in a prompt manner.
with the same school closing information. Please
be advised that individual schools will not be
listed separately, closings will always be listed by
district.
FACEBOOK, TWITTER & WEBSITE
WSD eNEWS
The WSD has its own Facebook page (Wentzville
The District publishes an electronic newsletter
School District) be sure to “like” us! It's a great
called the WSD eNews that is emailed to
way
parents/guardians who have students in our
happenings in the District, complete with pictures.
schools.
patrons
You can also follow the District on Twitter, just
information about what’s happening in the
search for WSDinfo. Both social media sites will be
District that affects our students, families, and
used not only to keep community members
community. The WSD eNews also sends out
informed about the latest news in the District, but
information via email regarding emergency
in the event of a school closing or emergency,
school closings. Community members can also
this will be yet another means of communicating
sign up to receive the eNews. You can stop
quickly and efficiently. The District website will also
delivery at any time simply by clicking on the
be updated with any emergency school closing
unsubscribe tab.
information. Please check on the homepage.
This
newsletter
gives
Timberland Times Newsletter designed by Megan Spotila
to
keep
up
to
date
with
the
latest
PAGE 8
THE DENTIST IS COMING TO SCHOOL
AT NO COST * TO YOU!
Taking care of your child’s teeth is important to keep them healthy.
Please complete, sign & return to your teacher in 2 days
Includes initial dental care & follow-up visits!
1. ABOUT YOUR CHILD
If your child already sees a dentist regularly, continue to go to that dentist.
School or Program Name___________________________________________________________County___________________
Teacher_________________________________________________________ Room #__________Grade___________ AM/PM
Child’s Legal Name____________________________________________ Child’s Date of Birth________________ Male/Female
Child’s Social Security Number ______ ______ ______ - ______ ______ - ______ ______ ______ ______
(circle one)
Parent/Guardian Name_____________________________________________________________________________________
(PRINT CLEARLY & SIGN BELOW)
Address____________________________________________________City/Zip______________________________________
Email______________________________________ Phone (
) __________________
MEDICAID & CHIP COVER 100% OF TREATMENT
2. INSURANCE INFORMATION
CHILD HAS MEDICAID/CHIP
Enter Child’s 8-digit
ID Number HERE:
)_______________ Alt. Phone (
Circle one of the following: Missouri Medicaid (MO HealthNet), HealthCare USA, Missouri Care, Home State Health Plan
*If your child is insured by Medicaid or CHIP.
Ins. Company name (other than Medicaid)________________________________________________ Ins. Phone________________________
Group #_________________________________Employer name________________________________Co. phone_________________________
Name of Insured Adult________________________________________________________ BIRTH DATE of Insured Adult _________________
Member ID/Policy #______________________________________________ Social Security # of insured adult_____________________________
If paying for services, please make check or money order payable to Nevin Waters, DDS, PA & staple to this form.
II am
a dental for
cleaning,
screening
fluoride per
visit. per visit.
am able
able to
to pay
pay the
the full
full fee
fee for
of $133.00
a dental
cleaning,&screening
& fluoride
CHILD
CHILD HAS
HAS NO
NO DENTAL
DENTAL INSURANCE
INSURANCE
IIcertify
I need
to pay
for a$60.00
subsidized
because
I am unable
to pay
theunable
full fee.to
It will
dental
screening
& cleaning,
fluoride per visit.
certifythat
that
I need
to pay
for aservice
subsidized
service
because
I am
paycover
the full
fee.cleaning,
It will cover
dental
screening & fluoride per visit.
II certify
nancial assistance,
uoride
certify that
that II am
am unable
unable to
to pay
pay the
the full
full or
or subsidized
subsidized fee
fee and
and request
request full
full fifinancial
assistance, which
which will
will cover
cover dental
dental cleaning,
cleaning, screening
screening && flfluoride
(charity
(charity care
care unavailable
unavailable for
for restorative
restorative treatment).
treatment). We
We will
will send
send you
you aa charity
charity care
care application.
application. Charity
Charity care
care available
available only
only once
once per
per school
school year.
year.
3. CHILD’S MEDICAL HISTORY
CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD
Notify us of any medical history changes.
List allergies (including allergies to medications) __________________________
Name/phone # of child’s physician______________________________________
___________________________________________________________
Use space below to provide additional details on your child’s health, including current medical
treatment, other significant past illnesses, alcohol & tobacco use (including smokeless). List current
medications. Attach another page as needed.__________________________________
____________________________________________________________
Recent Dental Problems
Sickle Cell Anemia
Asthma or Wheezing
Fainting /Epilepsy/Seizures
Behavioral Problems
Liver Problems/Hepatitis
Communicable Diseases/TB
Kidney Problems
Rheumatic Fever
HIV/AIDS
Diabetes
Cancer
Hemophilia/Bleeding Problems
Heart Problems - Describe ___________________________________
Approx. date of last dental visit. _________
CHECK IF ANTIBIOTIC PRE-MEDICATION REQUIRED FOR DENTAL TREATMENT
4. READ AND SIGN BELOW
I request that the dentist perform a dental check-up on my child at school which includes exam, cleaning, fluoride, sealants and x-rays as needed, as well as other dental
work as needed, including fillings, extractions of infected baby teeth, numbing the mouth and teeth and other procedures as described more fully on the back of this page.
This permission includes future dental visits. I have read the IMPORTANT NOTICE AND CONSENT ON THE BACK OF THIS PAGE and understand and agree to its terms.
SIGN & DATE HERE ___________________________________________________________ ____________
DATE
QUESTIONS:1-888-833-8441 Fax:1-888-330-4331
Nevin Waters, DDS, PA
435 Nichols Road, Suite 200, Kansas City, MO 64112
©Nevin Waters, DDS, PA, 2013
MO-COMPR-008-PDF
For your privacy, please fold & secure.
FOLD
FOLD
CHILD HAS PRIVATE DENTAL INSURANCE
IMPORTANT NOTICE & CONSENT / AVISO IMPORTANTE Y CONSENTIMIENTO
I understand and authorize Nevin Waters, DDS, PA (Provider) and its affiliated dentists to provide the following services for the named child for whom I am the custodial
parent or legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants. I authorize the dentist to fill any cavities or to
place a crown over the tooth if needed. I authorize Provider to extract any problem baby teeth or perform a pulpotomy (treatment of the nerves inside the tooth) as needed.
I understand that there are risks to dental treatment including swelling or pain that may occur from the injection of a local anesthetic or allergic reaction. (For additional
information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize & direct Provider to bill & collect payment from any
Medicaid, insurance, or other payer. If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co pays. Treatment by the in-school dentist
may affect future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at the
time of service, services will be provided without my presence. We may send you text messages about the school dental program. Message and/or data fees may be
charged by your wireless service provider; to discontinue, reply “STOP” to any message received from us. I have received the Notice of Privacy Practices (NPP) attached
to this form and consent to the release of my child’s medical record information, including records obtained from other providers, and any HIV/AIDS, communicable disease,
sexually transmitted disease, drug and alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor and/or administrative
service provider and their subcontractors for use and disclosure relating to my child’s treatment, payment for services and health care operation purposes. This signed
consent authorizes my child’s initial dental visit & follow-up visits. I may withdraw this consent at any time in writing to the address below.
Entiendo y autorizo a Nevin Waters, DDS, PA (Proveedor) y a sus dentistas afiliados a proveer los siguientes servicios al niño(a) mencionado del cual soy el padre custodio o tutor legal:
examen dental, limpieza de los dientes, tratamiento de fluoruro, rayos-x y sellantes. Autorizo al dentista a que atienda cualquier carie o coloque una corona sobre el diente si es necesario.
Autorizo al Proveedor a extraer cualquier diente de leche con problema o realizar una endodoncia (tratamiento de los nervios dentro del diente), como sea necesario. Entiendo que
existen riesgos al recibir tratamientos dentales incluyendo inflamación o dolor que puede ocurrir de la inyección de la anestesia o una reacción alérgica. (Para información adicional sobre
los riesgos del tratamiento dental y tratamientos alternos por favor llame al número de abajo.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado o
tercera persona. Si tengo seguro dental privado, seré facturado y acuerdo a pagar cualquier deducible y/o co-pago. El tratamiento realizado por el dentista escolar pudiera afectar los
beneficios de su niño en en un futuro bajo su cobertura privada, Medicaid o CHIP. Al menos de que allá hecho algún arreglo previamente para atender y estoy ahí al momento de los
servicios, el servicio será proveído sin mi presencia. En ocasiones podremos mandarle un texto sobre el programa dental escolar. Cobros de mensaje o/y de datos pueden ser aplicados
por su proveedor de servicios inalámbrico; para descontinuar, responda “STOP” a cualquier mensaje que reciba de nosotros. He recibido el Aviso de Prácticas Privadas (NPP) adjuntas
a este formulario y el consentimiento para la divulgación de la información y/o expediente médico de mi hijo(a), incluyendo los registros obtenidos de otros proveedores, y cualquier otra
enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisión sexual, drogas, alcohol, y anemia. Yo autorizo la divulgación de dicha información por parte
de proveedores para cualquier pagador responsable y/o proveedor de servicios administrativos y de sus subcontratistas para el uso y divulgación de información relacionada con el
tratamiento de mi hijo(a), pago para el mantenimiento y operación de cuidado dental. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Puedo
retirar mi consentimiento en cualquier momento por escrito a la dirección abajo.
KEEP FOR YOUR RECORDS
DR. NEVIN WATERS, DDS, PA
William Dillon, DDS, Perdita J Fisher, DMD, Andrea Gordon, DDS, Joseph Hughey, DDS, Adrienne Jennings, DDS, Maria Wong Kim, DMD, Eric Klumb, DDS, Joel Luedeke, DMD, Ronald Parkin, DMD, Cory Scanlon, DDS, Ronald Shrum, DDS,
Deedra Truschinger, DDS, Hillard Ullman, DDS, Jennifer Waller-Smith, DDS, Dewain Whitmore, DDS
NOTICE OF PRIVACY PRACTICES
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. KEEP FOR YOUR RECORDS
OUR LEGAL DUTY
The privacy of your medical information is important to us. 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 concern¬ing your health information. We must follow the privacy practices that are
described in this Notice while it is in effect. We will notify you if your unsecured medical information is breached.
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 changes. Before we make a significant change in our privacy
practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for
additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We 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, school nurse, or other healthcare
provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
S
D
R
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as
voicemail messages, postcards, letters, emails or text messages).
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for
the government to monitor the health care system, the outbreak of disease, government programs, compliance with civil rights laws
and to improve patient outcomes.
O
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Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We may
also disclose health information about you in response to a subpoena, discovery request or other lawful process.
RE
Other Uses and Disclosures. As permitted or required by law, we may use or disclose your medical information for research
purposes; to organizations that handle and monitor organ donation and transplantation; for workers’ compensation or similar
programs to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries
or illness; for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications or
problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed
to, or is at risk for contracting or spreading, a disease; to medical examiners to identify a deceased person or determine cause of
death; or to funeral directors to carry out their duties.
R
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PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in
writing to obtain access to your health information and fax your request to the number at the end of this Notice.
YO
Healthcare Operations: We may use and disclose your health information in connection with our business
operations such as reviewing the competence or qualifications of healthcare professionals and evaluating
practitioner and provider performance.
Disclosure Accounting: You have the right to receive a list of some disclosures we or our business associates have made of your
health information. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests.
Your Authorization: Uses or disclosures not otherwise described in this Notice may be made only with your
written authorization. In addition, we must obtain your written authorization to sell your medical information
or to use or disclose your information for marketing goods or services to you where we are paid to make the
communication. If you give us an 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 a written authorization, we cannot use or disclose your health information for any reason except those
described in this Notice.
Restriction: You have the right to request that we restrict our use or disclosure of your health information. We are not required to
agree to your request except when disclosure would be to your health plan, you (or someone on your behalf other than your health
plan) has paid in full for your health care, the disclosure relates to payment or health care operations, and the disclosure is not
otherwise required by law. If we agree to the restriction, however, we will abide by that agreement (except in an emergency).
To Your Family and Friends and Persons Involved in Your Care: We may disclose your health information to a
family member, friend or other person involved in your care to the extent necessary to help with your healthcare or
with payment for your healthcare. We may also disclose your medical information to disaster relief organizations to
help locate individuals during a disaster. We may also use or disclose your medical information to notify, or assist
in the notification, of a family member, a personal representative or a person responsible for your care of your location,
general condition or death. If you do not want us to disclose your medical information to family members or others in
these circumstances, please notify our HIPAA Officer at 623-434-9343 x1152.
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.
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Required by Law: We may use or disclose your health information when we are required to do so by law.
Public Safety: We may need to disclose medical information to law enforcement officials, such as in
response to a search warrant or a grand jury subpoena, or to assist law enforcement officials in identifying or
locating an individual, to report deaths that may have resulted from criminal conduct, and to report criminal
conduct on our premises.
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 your medical information to military authorities of Armed Forces or foreign military personnel
under certain circumstances; to authorized federal officials for lawful intelligence, counterintelligence, or other national security
activities, and to protect the president; and to a correctional institution or law enforcement official having lawful custody of an
inmate or patient under certain circumstances.
Alternative Communication: You have the right to request in writing that we communicate with you about your health information
by alternative means or to alternative locations specified in your written request.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in
written form upon request.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are con-cerned
that we may have violated your privacy rights, you may complain to us using the contact information listed at the end of this Notice.
You also may submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if
you choose to file a complaint with us or the U.S. Department of Health and Human Services.
Phone: 623-434-9343 x1152
email: hipaaofficer@smileprograms.com
Effective Date: August 1, 2013
¡EL DENTISTA VIENE A LA ESCUELA
SIN NINGÚN COSTO* PARA USTED!
Cuidar de los dientes de su niño(a) es importante para mantenerlos sanos
Por favor llene, firme y regrese a su maestro(a) en 2 días
¡Incluye atención dental inicial y visitas de seguimiento!
1. DIGANOS ACERCA DE SU NIÑO(A)
Si su hijo(a) ya visita un dentista regularmente, continúe con ese dentista.
Escuela o Nombre del Programa___________________________________________________ Condado___________________
Profesor_____________________________________________________________ # de Salón_______Grado_______ AM/PM
Nombre Legal del Niño(a)____________________________________________ Fecha de Nacimiento_________ Hombre/Mujer
(circule uno)
Seguro Social ______ ______ ______ - ______ ______ - ______ ______ ______ ______
Padre/Tutor Legal_________________________________________________________________________________________
ESCRIBA CLARO Y FIRME ABAJO)
Dirección_________________________________________________Ciudad/Código Postal_____________________________
Email___________________________________ Teléfono (
)_______________ Teléfono Alt. (
) __________________
2. INFORMACION DEL SEGURO MEDICAID Y CHIP CUBREN 100% DEL TRATAMIENTO
NIÑO(A) TIENE MEDICAID/CHIP
Escriba los 8-digitos # de
identificación del niño(a) AQUI
Circule uno de los siguientes: Missouri Medicaid (MO HealthNet), HealthCare USA, Missouri Care, Home State Health Plan
*Si su hijo(a) está asegurado por Medicaid o CHIP.
Nombre de la Comp. de Seguro (aparte de Medicaid)______________________________________ Tel. del Seg.________________________
# Grupo_________________________________Empleador________________________________Tel. del Empleador______________________
Nombre del Adulto Asegurado___________________________________________ FECHA DE NACIMIENTO del adulto Asegurado _________
# Póliza/ID__________________________________________ Seguro Social del Adulto Asegurado_____________________________________
DOBLE
DOBLE
NIÑO(A) TIENE SEGURO DENTAL PRIVADO
NIÑO(A) NO
NO TIENE
TIENE SEGURO
SEGURO DENTAL
DENTAL Si va a pagar por los servicios, por favor haga su cheque o giro postal a Nevin Waters, DDS, PA y engrápelo a esta forma.
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3. HISTORIA MEDICA DEL NIÑO(A)
Notifíquenos de cualquier cambio en el historial medico.
Liste alergias (incluya alergias a algún medicamento)__________________________
Nombre y # de Teléfono del Doctor______________________________________
Celula de la Hoz
Anemia/Ataques epilépticos /Desmayos ___________________________________________________________
Use el espacio de abajo para darnos información adicional sobre la salud de su niño(a), incluyendo cualquier
Problemas del Riñon
Problemas del Hígado/Hepatitis tratamiento que este recibiendo, alguna otra enfermedad de significado, uso de alcohol o tabaco (incluyendo
el que no se fuma). Liste todos los medicamentos que esta tomando. Adhiera otra página si es necesario.
VIH/SIDA
____________________________________________________________
UNICAMENTE SELECCIONE LA CONDICION(ES) QUE APLIQUE(N).
Problemas dentales recientes
Asma o problemas de respiración
Problemas de comportamiento
Enfermedades Transmisibles/TB
Fiebre Reumática
Cáncer
Diabetes
Hemofilia o problemas de sangrado
Problemas del Corazón. Describa ___________________________________ Fecha aprox. de la ultima visita dental _________
MARQUE SI REQUIERE ANTIBIOTICO ANTES DE OBTENER TRATAMIENTO DENTAL
4. LEA Y FIRME ABAJO
Solicito que el dentista realice una revisión dental a mi hijo(a) en la escuela la cual cubrirá el examen dental, limpieza, fluoruro, sellantes, y rayos-x como sean
necesarios, así como otros trabajos dentales según la necesidad, incluyendo rellenos, extracciones de dientes de leche infectados, adormecimiento de la boca y
dientes y otros procedimientos como se describe con más detalles en la parte posterior de esta página. Este permiso incluye visitas al dentista en el futuro. He leído
la ADVERTENCIA IMPORTANTE Y CONSENTIMIENTO EN LA PARTE POSTERIOR DE ESTA PAGINA, entiendo y estoy de acuerdo con sus términos.
FIRME Y FECHA AQUI ___________________________________________________________ ____________
FECHA
Preguntas: 1-888-833-8441 Fax:1-888-330-4331
Nevin Waters, DDS, PA
435 Nichols Road, Suite 200, Kansas City, MO 64112
©Nevin Waters, DDS, PA, 2013
MO-COMPR-008-PDF
Para su privacidad doble y asegure.
IMPORTANT NOTICE & CONSENT / AVISO IMPORTANTE Y CONSENTIMIENTO
I understand and authorize Nevin Waters, DDS, PA (Provider) and its affiliated dentists to provide the following services for the named child for whom I am the custodial
parent or legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants. I authorize the dentist to fill any cavities or to
place a crown over the tooth if needed. I authorize Provider to extract any problem baby teeth or perform a pulpotomy (treatment of the nerves inside the tooth) as needed.
I understand that there are risks to dental treatment including swelling or pain that may occur from the injection of a local anesthetic or allergic reaction. (For additional
information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize & direct Provider to bill & collect payment from any
Medicaid, insurance, or other payer. If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co pays. Treatment by the in-school dentist
may affect future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at the
time of service, services will be provided without my presence. We may send you text messages about the school dental program. Message and/or data fees may be
charged by your wireless service provider; to discontinue, reply “STOP” to any message received from us. I have received the Notice of Privacy Practices (NPP) attached
to this form and consent to the release of my child’s medical record information, including records obtained from other providers, and any HIV/AIDS, communicable disease,
sexually transmitted disease, drug and alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor and/or administrative
service provider and their subcontractors for use and disclosure relating to my child’s treatment, payment for services and health care operation purposes. This signed
consent authorizes my child’s initial dental visit & follow-up visits. I may withdraw this consent at any time in writing to the address below.
Entiendo y autorizo a Nevin Waters, DDS, PA (Proveedor) y a sus dentistas afiliados a proveer los siguientes servicios al niño(a) mencionado del cual soy el padre custodio o tutor legal:
examen dental, limpieza de los dientes, tratamiento de fluoruro, rayos-x y sellantes. Autorizo al dentista a que atienda cualquier carie o coloque una corona sobre el diente si es necesario.
Autorizo al Proveedor a extraer cualquier diente de leche con problema o realizar una endodoncia (tratamiento de los nervios dentro del diente), como sea necesario. Entiendo que
existen riesgos al recibir tratamientos dentales incluyendo inflamación o dolor que puede ocurrir de la inyección de la anestesia o una reacción alérgica. (Para información adicional sobre
los riesgos del tratamiento dental y tratamientos alternos por favor llame al número de abajo.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado o
tercera persona. Si tengo seguro dental privado, seré facturado y acuerdo a pagar cualquier deducible y/o co-pago. El tratamiento realizado por el dentista escolar pudiera afectar los
beneficios de su niño en en un futuro bajo su cobertura privada, Medicaid o CHIP. Al menos de que allá hecho algún arreglo previamente para atender y estoy ahí al momento de los
servicios, el servicio será proveído sin mi presencia. En ocasiones podremos mandarle un texto sobre el programa dental escolar. Cobros de mensaje o/y de datos pueden ser aplicados
por su proveedor de servicios inalámbrico; para descontinuar, responda “STOP” a cualquier mensaje que reciba de nosotros. He recibido el Aviso de Prácticas Privadas (NPP) adjuntas
a este formulario y el consentimiento para la divulgación de la información y/o expediente médico de mi hijo(a), incluyendo los registros obtenidos de otros proveedores, y cualquier otra
enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisión sexual, drogas, alcohol, y anemia. Yo autorizo la divulgación de dicha información por parte
de proveedores para cualquier pagador responsable y/o proveedor de servicios administrativos y de sus subcontratistas para el uso y divulgación de información relacionada con el
tratamiento de mi hijo(a), pago para el mantenimiento y operación de cuidado dental. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Puedo
retirar mi consentimiento en cualquier momento por escrito a la dirección abajo.
MANTENGA PARA SUS ARCHIVOS
DR. NEVIN WATERS, DDS, PA
William Dillon, DDS, Perdita J Fisher, DMD, Andrea Gordon, DDS, Joseph Hughey, DDS, Adrienne Jennings, DDS, Maria Wong Kim, DMD, Eric Klumb, DDS, Joel Luedeke, DMD, Ronald Parkin, DMD, Cory Scanlon, DDS, Ronald Shrum, DDS,
Deedra Truschinger, DDS, Hillard Ullman, DDS, Jennifer Waller-Smith, DDS, Dewain Whitmore, DDS
AVISO SOBRE PRACTICAS DE PRIVACIDAD
ESTE AVISO DESCRIBE CÓMO SU INFORMACIÓN MÉDICA PUEDE SER USADA Y DIVULGADA, Y COMO USTED PUEDE OBTENER ACCESO A DICHA
INFORMACIÓN. POR FAVOR LEA ATENTAMENTE. MANTENGA PARA SUS ARCHIVOS
NUESTRO DEBER LEGAL
La privacidad de su información médica es importante para nosotros. Somos requeridos por leyes federales y estatales aplicables a mantener
la privacidad de su información de salud. También somos requeridos a darle este Aviso acerca de nuestras prácticas de privacidad,
nuestros deberes legales y sus derechos respecto a su información de salud. Debemos seguir las prácticas de privacidad descritas en
este Aviso mientras se mantenga en efecto. Le notificaremos si es violada su información médica.
Reservamos el derecho de cambiar en cualquier momento los términos y prácticas de privacidad de este Aviso mientras tales cambios
sean permitidos por las leyes aplicables. Reservamos el derecho de hacer cambios eficazmente en nuestras prácticas de privacidad y los
nuevos términos de nuestro Aviso para toda la información médica que mantenemos, incluyendo información de salud creada o recibida
antes de hacer los cambios. Antes de efectuar algún cambio significante a nuestras prácticas de privacidad, cambiaremos este Aviso y lo
haremos disponible a su pedido.
Puede solicitar una copia de nuestro Aviso en cualquier momento. Para más información de nuestras prácticas de privacidad, o para
copias adicionales de este Aviso, por favor póngase en contacto con nosotros usando la información que aparece al final de este Aviso.
USO Y DIVULGACION DE INFORMACION DE SALUD
Usamos y damos su información de salud para fines de tratamiento, facturación y operaciones de salud. Por ejemplo:
Tratamiento: Podemos usar o dar su información de salud a su médico, enfermera de la escuela o otro proveedor de salud que le esté
proveyendo tratamiento.
Pagos: Podemos usar y dar su información de salud con fines de obtener pago por los servicios proveídos por nosotros a usted.
Operaciones de Atención Médica: Podemos usar y dar su información médica con respecto a nuestras operaciones de negocio tales
como revisión de competencia o calificación de los profesionales de salud y evaluación del rendimiento profesional y proveedor.
Su Autorización: Usos o divulgaciones no descritas en esta notificación pueden hacerse solo con su autorización por escrito. Además,
debemos obtener su autorización por escrito para vender su información médica o para usar o dar su información para la comercialización
de bienes o servicios a usted donde nos pagan para hacer la comunicación. Si usted nos da una autorización, usted puede anularla
por escrito en cualquier momento. Su anulación no afectara cualquier uso o divulgación permitida por su autorización, mientras este en
efecto. A menos que usted nos dé una autorización por escrito, no podemos usar o divulgar su información médica por cualquier motivo
excepto los descritos en este Aviso.
A Su Familia y Amigos y Personas Involucradas en su Cuidado: Podemos dar su información médica a un familiar, amigo o otra
persona involucrada en su cuidado en la medida necesaria para ayudar con su salud o con el pago de su atención médica. También
podemos dar su información médica a organizaciones de ayuda de desastre para ayudar a localizar a individuos durante un desastre.
También podemos utilizar o divulgar su información médica para notificar, o asistir en la notificación, de un miembro de la familia, un
representante personal o una persona responsable de la localización de su cuidado, condición general o muerte. Si no desea que demos
su información médica a miembros de la familia o otras personas en estas circunstancias, por favor notifique a nuestro oficial de HIPAA al
623-434-9343 x1152.
Requerido por La Ley: podemos utilizar o dar su información médica cuando estemos obligados a hacerlo por ley.
Seguridad Pública: Podremos dar información médica a oficiales la ley, para responder a una orden de allanamiento o una citación
del gran jurado, o para ayudar a los oficiales de ley a identificar o localizar a un individuo, o para reporte de una muerte que pudo haber
resultado por conducta criminal e informar una conducta criminal en nuestras instalaciones.
Abuso o Negligencia: Podemos dar su información médica a autoridades apropiadas si razonablemente creemos que usted es una víctima
de abuso, negligencia o violencia doméstica o la posible víctima de otros delitos. Podemos dar su información de salud en la medida
necesaria para evitar una amenaza grave para su salud o seguridad o la salud o la seguridad de los demás.
Seguridad Nacional: Podemos dar su información médica a las autoridades militares de las fuerzas armadas o de personal militar
extranjero bajo ciertas circunstancias; a funcionarios federales de la ley de inteligencia legal, contrainteligencia y otras actividades de
seguridad nacional y para proteger al Presidente; y a un oficial de la ley o institución correccional que tiene la tutela legal de un preso o
paciente bajo ciertas circunstancias.
Recordatorios de citas: Podemos utilizar o dar su información médica para proporcionarle recordatorios de citas (por ejemplo, mensajes
de voz, tarjetas postales, cartas, correos electrónicos o mensajes de texto).
Actividades de Supervisión de Salud: Podemos dar información médica a una agencia de supervisión de salud para actividades
autorizadas por la ley. Estas actividades de supervisión por ejemplo incluyen, auditorías, investigaciones, inspecciones y encuesta de
licencia. Estas actividades son necesarias para el gobierno para controlar el sistema de salud, el brote de enfermedades, programas de
gobierno, el cumplimiento de las leyes de derechos civiles y para mejorar los resultados del paciente.
Demandas y Disputas: Podemos dar información médica sobre usted para responder a una orden judicial o administrativa. También
podemos dar información médica sobre usted en respuesta a una citación, solicitud de descubrimiento o otro proceso legal.
Otros Usos y Revelaciones: Podemos utilizar o dar su información médica para fines de investigación; a las organizaciones que manejan
y monitorear la donación de órganos y trasplante, como sea permitido o requerido por la ley; para la compensación de trabajadores o
programas similares a cumplir con las leyes relacionadas con la compensación de trabajadores o programas similares que proporcionan beneficios
para lesiones relacionadas con el trabajo o la enfermedad; para actividades de salud pública tales como para prevenir o controlar
enfermedades, lesiones o incapacidades; para reportar reacciones a medicamentos o problemas con productos; notificar a las personas
de revocaciones de productos que pueden estar usando; para notificar a una persona que pudo haber sido expuesta a, o corre el riesgo
de contraer o esparcir una enfermedad; a médicos forenses para identificar a una persona fallecida o determinar causa de muerte; o a
directores de funerarias para llevar a cabo sus funciones.
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DERECHOS DEL PACIENTE
Acceso: Usted tiene el derecho a ver o obtener copias de su información médica, con excepciones limitadas. Usted debe hacer
una petición por escrito para obtener acceso a su información de salud y enviar su solicitud por fax al número al final de este
Aviso.
Contabilidad de Divulgación: Usted tiene el derecho a recibir una lista de algunas revelaciones que hemos hecho nosotros o
nuestros asociados de negocios de su información médica. Si usted ha solicitado esta información más de una vez en un período
de 12 meses, podríamos cobrarle una cuota razonable, basado en los costos para responder a estas solicitudes adicionales.
Restricciones: Usted tiene el derecho a solicitar que restrinjamos el uso o divulgación de su información de salud. No estamos
obligados a aceptar su solicitud, excepto cuando la divulgación sería a su plan de salud, usted (o alguien en su nombre que no
sea su plan de salud) ha pagado total para el cuidado de su salud, la divulgación se refiere al pago o operaciones de cuidado
de la salud, y la divulgación de lo contrario no es requerida por ley. Sin embargo, si estamos de acuerdo a la restricción, nos
regiremos por ese acuerdo (excepto en caso de emergencia).
Comunicación Alternativa: Usted tiene el derecho de solicitar por escrito que nos comuniquemos con usted acerca de su
información médica por medios alternativos o a lugares alternativos especificados en su petición.
Enmienda: Usted tiene el derecho de solicitar que nosotros enmendemos su información de salud. Su petición debe ser por
escrito y debe explicar por qué se enmiende la información. Podemos negar su petición bajo ciertas circunstancias.
Aviso Electrónico: A su petición, usted tiene derecho a recibir esta notificación por escrito, si usted recibe este Aviso en nuestro
sitio Web o por correo electrónico (e-mail).
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PREGUNTAS Y QUEJAS
Si desea más información sobre nuestras prácticas de privacidad o tiene preguntas o inquietudes, por favor comuníquese con
nosotros. Si usted está preocupado que podemos haber violado sus derechos de privacidad, puede quejarse con nosotros por
medio la información que aparece al final de este Aviso. Usted también puede presentar una queja por escrito al Departamento
de Salud y Servicios Humanos de los Estados Unidos. No tomaremos represalias de ninguna manera si usted decide presentar
una queja con nosotros o con el Departamento de Salud y Servicios Humanos de los Estados Unidos.
Contacto oficial: Oficial de HIPAA
Teléfono: 623-434-9343
email: hipaaofficer@smileprograms.com
Fecha efectiva: August 1, 2013