Patient Information Dental & Health History HIPAA & Consent Form Office Policy 1 Patient Information2 Dental Insurance Date* SS/HIC/Patient ID NumberPatient Name* Last Name First Name Middle Initial Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code E-mail Sex* Male Female Birthdate* Age*Marital Status* Married Separated Widowed Divorced Single Minor Patient Employer/ SchoolOccupationEmployer/ School Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer/ School PhoneSpouse's Name First Name Last Name Birthdate SSNSpouse's EmployerWhom may we thank for referring you?* Phone Numbers Phone NumberOffice NumberExtensionAlternative NumberSpouse's Work NumberBest time and to reAlt. you : HH MM AM PM IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.) Name* First Name Last Name Relationship*Phone*Work Phone Who is responsible for this account?*Relationship to Patient*Insurance CompanyGroup NumberIs the patient covered by additional insurance* Yes No Subscriber's Name First Name Last Name Birthdate Relationship to Patient*Insurance CompanyGroup Number ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage withName of Insurance Company(ies)and assign directly toName of Physicianall insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-name dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.Signature of Patient, Parent, Guardian or Personal Representative Please print name of Patient, Parent, Guardian or Personal Representative DateRelationship of Patient 1 Dental History2 Health History Reason for today's visit*Former DentistCity/ StateDate of last dental visit* Date of last dental X-rays Place a mark on "Yes" or "No" to indicate if you have had any of the following: Bad breath*YesNoBleeding gums*YesNoBlisters on lips or mouth*YesNoBurning sensation on tongue*YesNoChew on one side of mouth*YesNoCigarette, pipe, or cigar smoking*YesNoClicking or popping jaw*YesNoDry mouth*YesNoFingernail biting*YesNoFood collection between the teeth*YesNoForeign objects*YesNoGrinding teeth*YesNoGums swollen or tender*YesNoJaw pain or tiredness*YesNoLip or cheek biting*YesNoLoose teeth or broken fillings*YesNoMouth breathing*YesNoMouth pain, brushing*YesNoOrthodontic treatment*YesNoPain around ear*YesNoPeriodontal treatment*YesNoSensitivity to cold*YesNoSensitivity to heat*YesNoSensitivity to sweets*YesNoSensitivity when biting*YesNoSores or growths in your mouth*YesNoHow often do you floss?* Physician's NameDate of last visit Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.* Yes No Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).* Yes No Place a mark on "Yes" or "No" to indicate if you have had any of the following: AIDS/HIV*YesNoAnemia*YesNoArthritis, Rheumatism*YesNoArtificial Heart Valves*YesNoArtificial Joints*YesNoAsthma*YesNoBack Problems*YesNoBleeding abnormally, with extractions or surgery*YesNoBlood Disease*YesNoCancer*YesNoChemical Dependency*YesNoChemotherapy*YesNoCirculatory Problems*YesNoCongenital Heart Lesions*YesNoCortisone Treatments*YesNoCough, persistent or bloody*YesNoDiabetes*YesNoEmphysema*YesNoDo you wear contact lenses?*YesNoEpilepsy*YesNoFainting or dizziness*YesNoGlaucoma*YesNoHeadaches*YesNoHeart Murmur*YesNoHeart Problems*YesNoHepatitis*YesNoHepatitis TypeHerpes*YesNoHigh Blood Pressure*YesNoJuandice*YesNoJaw Pain*YesNoKidney Disease*YesNoLiver Disease*YesNoLow Blood Pressure*YesNoMitral Valve Prolapse*YesNoNervous Problems*YesNoPacemaker*YesNoPsychiatric Care*YesNoRadiation Treatment*YesNoRespiratory Disease*YesNoRheumatic Fever*YesNoScarlet Fever*YesNoShortness of Breath*YesNoSinus Trouble*YesNoSkin Rash*YesNoSpecial Diet*YesNoStroke*YesNoSwollen Feet or Ankles*YesNoSwollen Neck Glands*YesNoThyroid Problems*YesNoTonsilitis*YesNoTuberculosis*YesNoTumor or growth on head or neck*YesNoUlcer*YesNoVenereal Disease*YesNoWeight Loss, unexplained*YesNo Women Are you Pregnant?* Yes No Taking birth control pills? Yes No Due date Are you nursing?* Yes No Medications List any medications you are currently taking and the correlating diagnosis:*Pharmacy NamePhoneAllergies*AspirinBarbiturates (Sleeping pills)CodeineIodineLatexLocal AnetheticPenicilinSulfaPatient's Signature*Date* Doctor's Signature*Date* Has there been any change in your health since your last dental appointment?* Yes No If yes, for what conditions?Are you taking any new medications?*If so, what?Patient's Signature*Date* Doctor's Signature*Date* HIPAA Information and Consent FormThe Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov We adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. *NameDate datedo hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM any subsequent changes in the office policy. I understand that this consent shall remain in force from this time forward.Email* Phone* Our Dental office would like to “welcome you”! We will take the utmost care and concern for your dental needs. We have a state of the art office with a caring staff. You are very important to us and we would like to make you a part of our dental family. Please see our office policies below: Payment's Our office will always give you a treatment plan for any of your dental needs. We take Cash, and Visa, Master Charge, Discover. Financing We also have our In house financing with “Care Credit” and “Springstone” if your dental needs are beyond the cost of your insurance or if you don't have insurance. Please ask about an application at our reception area. Broken Appointments Also we schedule all appointments for our patient's and to be considerate to others we do require a confirmation call back before all appointments made and if we do not here from you within 48 hrs to confirm we do charge a fee of $25.00 for a broken/canceled appointments. Transfer's of Xrays We also take the state of the art digital xrays and if the patient transfer's out of our office we do charge $25.00 for the xrays. I understand the office policies that were presented to me.SignatureDate
