Adult Patient Forms
For new patients ages 16+, please complete the following forms:
Child Patient Forms
For new patients ages 0-15, please complete the following forms:
At Health Centered Dentistry, keeping your personal health information private is very important to us. We have set practices in place to protect your information. These practices include:
- How HCD will use and disclose my protected health information
- My privacy rights with regard to my protected health information
- HCD’s obligations concerning the use and disclosure of my protected health information.
The Notice of Privacy Practices may be revised from time to time and, as a patient, you are entitled to receive a copy of any revised Notice of Privacy Practices upon request.
If you have any questions or complaints, you may contact Rachael Middleton at (907) 276-4537 or [email protected]. You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Their contact information can be found HERE.
Discrimination is Against the Law. Health Centered Dentistry (HCD) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HCD does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. HCD:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters,
- Written information in other formats (large print, audio, accessible electronic formats, other formats).
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters,
- Information written in other languages.
If you need these services or if you believe that HCD has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Rachael Middleton, Chief Operations Officer, is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available here.
“Staff is a perfect blend of personable and professional. They employ the latest technology to monitor and treat my dental health. I feel they live into their name and look at the whole picture in addressing my wellness.