Patient Care

PATIENT FORMS

Please complete the following forms as needed for your upcoming appointment. Having these forms filled out prior to your appointment will help ensure a timely start and accurate estimates for your insurance.

 

Insurance

Insurance is a valuable asset to help cover your dental care needs. We accept all insurance plans except for Medicaid and Medicare. We are not preferred providers for insurance companies but are happy to submit claims on your behalf.

CareCredit

We accept Care Credit to make it possible for your needed or cosmetic dental work. We never want our patients to have to choose between their other responsibilities and their health. CareCredit is a credit card with special financing options for health care that allows you to make payments. CareCredit not only works at our office, but also is accepted in many other health care offices and even some veterinarian clinics!

You can speak with our team at the front desk to learn more about financial options or discounts available to you!

 

 
 

HIPAA / PRIVACY POLICY

At Evergreen Dental, 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 Evergreen will use and disclose my protected health information

  • My privacy rights with regard to my protected health information

  • Evergreen'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 Mikhayla Chapman at 907.531.3477 or evergreendentalak@gmail.com. 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 at HERE.

Click HERE to read Evergreen Dental’s Notice of Privacy Practices.

 

NON-DISCRIMINATION CLAUSE

Discrimination is Against the Law.

Evergreen Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Evergreen does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Evergreen:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:

    1. Qualified sign language interpreters,

    2. 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:

    1. Qualified interpreters,

    2. Information written in other languages.

 

If you need these services or if you believe that Evergreen 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:

  • Mikhayla Chapman, Office Manager
    125 W Evergreen Avenue, Suite 204, Palmer, AK 99645
    P: (907) 531-3477, F: (907) 531-3478
    mikhayla@evergreendentalak.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Mikhayla Chapman, Office Manager, 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.

Phone

125 W Evergreen Avenue

Suite #204, Palmer, AK 99645

Wednesdy - Friday

10:00am - 5:00pm

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