Have you had or currently have any history of the following?
I certify that the above information is true, and to the best of my knowledge.
Check appropriate response:
Check all that apply:
Do you frequently awaken with:
According to the following scale choose the appropriate number value to represent how likely you are to fall asleep during the day in the following situations. Try to be honest as possible. If possible, have your significant other help you fill this out.
This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information. Please Review It Carefully.
Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- To other health care providers (i.e. your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleanings, surgery, etc.)
- To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of payment, etc.)
- To certifying, licensing and accrediting bodies (i.e. American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation.
- Internally, to all staff members who have any role in your treatment.
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
- To your family and close friends involved in your treatment.
- To contact you in order to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
- To email your x-rays, photos, and treatment plan to your other doctors as needed.
- To leave messages or email you regarding upcoming appointments.
Your Rights Regarding Your Health Information
You may ask us to communicate with you in a confidential manner, ask to see or obtain photocopies of your health information and/or ask us to amend your health information if you feel that it is inaccurate or incomplete.
Acknowledgements and Permissions
PLEASE INITIAL OR WRITE "NO" ON THE FIRST TWO LINES. INITIAL THE THIRD LINE!
I hereby acknowledge that I have received, read and reviewed a copy of this notice of Privacy Practices, the consent to treatment and office procedures. I authorize use of my signature on and release of information for insurance submissions.