Responsible Party

Emergency information

Medical History

Dental History


Dental Insurance Inquiry Form

Dr. Hom may be an “Out of Network” Provider

HIPAA Consent & Acknowledgment Information Form

  • (1) Patient information will be kept confidential except as is necessary to provide treatment or to ensure that all administrative matters related to your care handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, as is necessary and appropriate for you care. Patient files may be stored in open file racks but will not contain any coding which identifies a patient’s condition or information which is not already a matter of public records. The normal course of providing care means that such records may be left in administrative areas such as the front office, Doctor’s office etc. The patient agrees to the normal procedures utilized within the facility for the handing of charts, patient records, PHI and other documents or information.
  • (2) It is the policy of the office to remind patients of their appointments. This may be done by telephoning patients or by any other means convenient for the practice.
  • (3) The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but agree to abide by the confidentiality rules of HIPAA.
  • (4) The patient understands and agrees to inspections of the office and the review of documents which may include PHI by government agencies or insurance companies in the normal performance of their duties.
  • (5) The patient agrees to bring any concerns or complains regarding privacy to the attention of the Doctor or office manager.
  • (6)Your confidential information will not be used for purposes of advertising or marketing of products, goods or services. Such prohibition does not include treatment/ product samples or goods of nominal value.
  • (7)The practice agrees to provide the patient with access to their records in accordance with state law.
  • (8)The practice may change, add, delete, or modify any of these provisions to better serve the needs of 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 changes on certain policies used within the office concerning your PHI. However, the practice is under no obligations to alter internal policies to conform to your request.
  • (10)There is no patient right to litigation under HIPAA.