Patient Forms and Policy

Please complete your New Patient form by on the link below. Once completed, the form will be automatically uploaded to our office database.

Financial Policy

Welcome! Thank you for selecting us as your dental health care providers. Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and as comfortable as possible throughout our relationship. We encourage you to ask questions and to be involved in treatment decisions. This includes understanding your treatment plan as well as our financial policy.

Financial Agreement

Patients are expected to pay for our services at the time they are rendered. Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service. Payments may be made using cash, check, Visa, MasterCard, Discover, and or American Express. 

There will be a fee for any additional procedure NOT included in the original treatment plan.

Insurance Information

As a courtesy to our insured patients, we submit claims to your insurance company free of charge. We will help you receive your maximum allowable benefits.

Burns Dental Associates diagnoses treatment based on your dental health not your insurance coverage.

If your insurance company has not paid within 60 days of services rendered, you will need to make full payment to this office and reimbursed when your insurance company pays. After 60 days the patient is responsible to pursue payment from the insurance company. All current documentation will be provided by mail or e-mail in order to assist with any inquires. The insured has a better ability to deal with the insurance company and the employer responsible for the policy.

Please indicate your understanding and acceptance of these financial policies by singing below. For the mutual convenience of you and the practice, it is understood that this executed copy of the Financial Policy also shall cover your dependent children who are patients of the practice.

Appointment Policy

Our Team at Karen Burns D.M.D. Dental and Facial Aesthetics is committed to providing the highest quality dental care and services for our patients. Dental Procedures require preparation and planning. This includes appropriate staffing, treatment room availability and material preparation at specific times during our work day. If you have made an appointment with us, that time has been reserved exclusively for you and we have prepared in advance for your visit. Please be advised of the following requirements:

– We request 48 hours’ notice for cancellation of a scheduled appointment.

– A cancellation fee of $75 per hour will be added for all missed or cancelled appointments with less than 24 hours’ notice.

– If there are three missed or cancelled appointments without 24 hour notice in a year time frame, we reserve the right to not schedule any further appointments or to require a deposit in order to schedule a future appointment.

– Family Emergencies will be taken into consideration. We understand that extenuating circumstances or emergencies do occur…please call us as soon as possible and we’ll work it out.

Deposit Policy

When scheduling an appointment requiring 2 or more hours a deposit is required in order to confirm and hold your appointment. This amount will be applied to your out of pocket expenses. These deposits must be made prior to scheduling the appointment. If the appointment is cancelled or broken with less than 48 hours advance notice, the deposit is non-refundable.

Notices of Private Practices

Notice of Privacy Practices for Protected Health Information 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!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

  • Example of uses of your health information for treatment purposes: 
    A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.
  • Example of use of your health information for payment purposes: 
    We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.
  • Example of Use of Your Information for Health Care Operations: 
    We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights 

The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office.
  • We are not required to grant the request but we will comply with any request granted;
  • Request that you be allowed to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our office;
  • Appeal a denial of access to your protected health information except in certain circumstances;
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,
  • Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact our administrator, in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to exercise your rights.

 Our Responsibilities

The practice is required to:

  • Maintain the privacy of your health information as required by law;
  • Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
  • Abide by the terms of this Notice;
  • Notify you if we cannot accommodate a requested restriction or request; and
  • Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our office administrator.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our office administrator. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address is 200 Independency Ave. S.W. Washington, D.C., 20201, phone # 1- 877-696-6775,

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.

We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Disclosers and Uses


Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers  Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect 

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional  Institutions 

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight 

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative  Proceedings 

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses 

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.


If we maintain a website that provides information about our entity, this Notice will be on the website. Effective Date: 07/01/2016

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