Patient Contact Information

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PRIMARY ORTHODONTIC INSURANCE
SECONDARY ORTHODONTIC INSURANCE

HEALTH HISTORY

MEDICAL HISTORY

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DENTAL HISTORY

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Any injuries to:

EMERGENCY CONTACT INFORMATION

By signing the following, I certify that all information listed above is correct and I grant permission to Dr. Jeffrey Mastroianni to take records for the purpose of making a proper diagnosis and treatment plan for the patient listed above. These records include a panorex, lateral cephalogram, digital photos, models of the patient’s teeth, and other diagnostic aids. I understand that it is not possible to begin orthodontic treatment without gathering all of the necessary records

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect , and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualification of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, 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 a written authorization,we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. 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.

Person Involved in Care: We may use ofor 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, your general condition, or death. If you are present, then prior to use of 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 judgement disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-­‐rays, or 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 when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a 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 or the health or 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 authorized, federal officials health information required for lawful intelligence, counter-intelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, letters or postcards).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other that photocopies. We will use the format you request unless we cannot practicably do so. (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 and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0. for each page, $ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-‐based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

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 other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-‐month period, we may charge you a reasonable, cost-‐based fee for responding to these additional request.

Restriction: You have the right 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. (You must make your request in writing.) your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you 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.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-‐mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to 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 the 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.

Your Orthodontic Appointments

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In order to ensure quality orthodontic care, it is important that both parents and patients understand the manner in which we schedule your appointments. Our goal is to be the best part of your day and we make it a priority to value both you and your time. Therefore, we make every effort to stay on or ahead of schedule. lnconveniencing your work schedule and interrupting your child’s studies as infrequently as possible is very important to our entire office. Since the vast majority of our patients are of school age, it is unavoidable that some school-time appointments will be necessary.

We are glad to work around your child's important classes and provide your child with school excuses for scheduled orthodontic appointments. It is important for your child to turn these into the appropriate school official.

Our team works hard to provide the finest orthodontic care using the most convenient scheduling system possible for you and your child. Because we have families of our own, we understand your scheduling concerns and will do everything we can to ensure your child’s treatment goes as smoothly as possible.


  • LONG APPOINTMENTS, BANDING, AND BONDING: These are more detailed and technique- sensitive appointments. Therefore, these appointments will be scheduled during Doctor’s quiet time which is late morning and early afternoon.
  • ORTHODONTIC DISCOMFORT: (Pain, swelling, or bleeding) This usually results from trauma to the face or mouth. These patients will be seen as soon as possible and either appropriate care given or referral to another specialist provided for treatment.
  • REPAIRS: (Loose bands or brackets, broken archwires or ties, broken appliances or retainers) These appointments are always scheduled specifically during school hours since they are long visits. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our long-visit patients during school hours, it leaves more room in our schedule to see patients during after-school hours.
  • APPOINTMENTS BROKEN OR NOT CANCELLED WITHIN 48 HOURS: Another appointment will be scheduled but may require waiting four to six weeks. An appointment made during school hours may be arranged sooner.
  • GENERAL DENTIST APPOINTMENTS: As treatment progresses, it is important to continue seeing your regular dentist every six months for a checkup and cleaning.

Thank you so very much for understanding!

I have read and agree to the scheduling information above:

2220 S. State Route 157 • Suite 125 • Glen Carbon, IL 62034 • 618-288-0600
4905 Stone Falls Center Drive • Suite A • O'Fallon, IL 62226

Patient Disclosure Form

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In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual’s home.

Protecting Your Health Information:

I allow you to release my clinical and/or financial information to and/or answer questions from:

Communication Via Email:

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by authorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication.

I consent and accept the risk in receiving information via email. I understand I can withdraw my consent at any time. My email address is:

I do not consent to receive any clinical and/or information via email. I understand that I can change my mind and provide consent later.

PreviDent 5009 Booster Plus:
Overview:

PreviDent® 5000 Booster Plus is a fluoride toothpaste that is easily applied onto a toothbrush. This prescription toothpaste should be used once daily in place of your regular toothpaste unless otherwise instructed.

Dosage and Administration:

Patients 6 years of age or older, apply a thin ribbon of PreviDent® 5000 Booster Plus to a toothbrush. Brush teeth thoroughly once daily for two minutes, preferably at bedtime, in place of your regular toothpaste. For best results, do not eat, drink, or rinse for 30 minutes.

Preferred Pharmacy for Prescription Toothpaste:

Photo/Video Release:

For valuable consideration received, I hereby grant to Mastroianni Orthodontics and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish video and/or photographs of me, or in which I may be included, for editorial, trade, advertising such as the Internet and/or Facebook and any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release the photographer and his/her legal representatives and assigns from all claims and liability relating to said photographs. (Please check the applicable box)

Relationship to Patient
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