Acknowledgement of Receipt of Notice of Privacy Practices
Please print, sign, and bring this page to your appointment to confirm you have received our Notice of Privacy Practices.
Patient forms
Forms to download
Only some of these need to come back to us. The forms in the first group should be printed, completed, signed, and brought to your appointment. Please don't email completed forms back, they contain personal health information. Questions? Call us at (970) 237-4313.
Print, sign, and bring with you
General Dentistry Informed Consent
Please print, sign, and bring this form. It explains common procedures, their benefits, risks, and alternatives.
Health History
Print, complete, sign, and bring with you. Covers everything on the ADA health history form, with a separate medical alerts section for antibiotic premedication and infective endocarditis.
Patient Code of Conduct
Our mutual respect policy: the dignity and respect we commit to showing you, and the conduct we ask in return, including what may happen if behavior becomes abusive, threatening, or disruptive.
Records Release
Print and sign to authorize us to release your dental records, or to request your records from another provider.
Insurance and self-pay
If you have dental insurance, start with the insurance information form and the coverage check below. We do not participate in Health First Colorado (Medicaid) or Child Health Plan Plus (CHP+).
Insurance Information
If you have dental insurance, print, complete, and bring this form with your insurance card so we can file your claims for you. Covers primary and secondary coverage, with the authorization signature we need to bill your plan.
What "in network" and "out of network" mean
In network means the dentist has a contract with your insurance plan. Fees follow the plan's negotiated rates, and your share is usually lower.
Out of network means there is no contract. You can still be treated here, but your plan may pay less, pay you directly instead of us, or apply a separate deductible, so your share may be higher. Either way, we will file your claims for you and tell you your estimated portion before treatment begins.
How to check whether we are in your network
Give your insurance company this information:
Dentist: Jill Kollar, DMD
NPI: 1093069973
Precision Dental of Windsor
1580 Main Street, Suite B, Windsor, CO 80550
Then ask: "Is Jill Kollar at Precision Dental of Windsor in network for my plan?" The member services number is printed on the back of your insurance card. Common plans:
Delta Dental of Colorado provider search, 1-800-610-0201
Cigna provider search, 1-800-244-6224
Aetna DocFind provider search, 1-855-496-6289
MetLife find a dentist, 1-888-262-4874
Your right to a Good Faith Estimate
If you do not have dental insurance, or you choose not to use it, you have the right to a written Good Faith Estimate of the expected cost before scheduled treatment. Ask us and we will prepare one.
If your final bill is $400 or more above the estimate, federal law gives you the right to dispute it.
For your reference
Notice of Privacy Practices
How we use and protect your health information, and the rights you have regarding it. Effective October 9, 2026. For your reference, there is no need to print or sign this notice; the acknowledgement above is the page we need back.