Medical Dental History Form

Health Care Privacy Act

NOTICE OF PRIVACY PRACTICES (DENTAL) This notice describes how medical/dental information about you may be used and disclosed and how you can obtain access to this information. Please Review Carefully The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

Treatment: means providing, coordinating, or managing health care related services by one or more health care providers.
Payment: means using and disclosing your identifiable health information to obtain payment for services we provide to you, confirming coverage, billing and collection activities and utilization review.
Health Care Operations: means using and disclosing your identifiable health information in connection with running of our practice, including quality assessment and improvement activities,

auditing functions, cost management analysis, customer service, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. In the event this office has already obtained consent from you for the use & disclosure of health information, we may continue to rely on that consent for the purposes specified. Consent Unnecessary: our office may use and disclose your health information without your prior consent if it is “de-identified”, meaning that all references are removed that could be used to trace the information to a specific individual. In addition, your prior consent is not necessary to use or disclose protected health information in connection with treatment, payment, or healthcare operations in the following circumstances: Emergency Treatment: in our professional judgment, should you need emergency treatment and we cannot obtain consent prior to such treatment, we will attempt to obtain such consent, however, as soon as practicable after the delivery of such service. Required by law: if we are required by law to treat you and we attempt to obtain such consent but are unable to do so; or if we are unable to obtain your consent due to substantial barriers to communicating with you. And in our professional judgment we determine that your consent to treatment is inferred from the circumstances. Authorization: any use or disclosure of your health other than for treatment, payment or health care operations will be made only with your written authorization. You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this notice. Opportunity to Object: We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, or your general condition. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical/dental supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information if required by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety of the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to any authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with your appointment reminders (such as voicemail/answering machine messages, postcards, e-mail, or letters). Your Rights: Access: You have the right to inspect and obtain a copy of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies, postage and staff time. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain activities, for the last 6 years, but not before April 14, 2003. If your request for accounting is for more than a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. Your request must be made in writing and must specify the alternative means or location, and provide satisfactory explanation of how payment will be handled under the alternative means or location at your request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. Questions & Complaints: If you want more information about our privacy practices or if you have any questions or concerns, please contact us. If you feel that your privacy protections have been violated, you have the right to file a formal written complaint with us at the address listed below, or with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Information: Privacy Officer’s Name: Christina Scandiffio Phone: (301) 654-7910 E-Mail: Christina@hallmanorthodontics.com Address: 5530 Wisconsin Ave, Suite 1525: Chevy Chase, MD 20815 *LARGER PRINT AVAILABLE UPON REQUEST

Signature

Date

Write your full name acknowledges that you have been informed of your privacy rights.

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus”, at any time or in any place. Be assured that we have always followed state and federal regulations and recommenced universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff, and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

Yes No

Patient Name

Parent/Guardian Name (if applicable)

Relation

Patient/Parent/Guardian Signature

Date

Medical Dental History Form

PATIENT

PARENT/GUARDIAN (for patients under 18)

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

SECTION A- PATIENT HEALTH INFORMATION FOR PATIENTS OVER 18, PLEASE SKIP TO SECTION B FOR MINORS

MEDICAL HISTORY

DENTAL HISTORY

FAMILY MEDICAL HISTORY

SECTION B - PATIENT HEALTH INFORMATION FOR MINORS

MEDICAL HISTORY

MEDICAL HISTORY continued

DENTAL HISTORY

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Health Care Privacy Act