Adult New Patient

WELCOME TO OUR OFFICE

Chart #

ADULT PATIENT INFORMATION:

Name:

Prefer to be called:

Sex:

Home Address:

City:

State:

Zip:

Birthdate:

Age:

Home Phone:

Cell Phone:

Email:

Preferred Method of Contact:

Patient’s Dentist:

Date of last dental checkup or cleaning?

Who noticed your orthodontic problem?

You Dentist Other

Describe your orthodontic problem in your own words:

Occupation:

Employer:

Address

WK Phone

Whom may we thank for referring you to our office?

Family and Account Information:

Spouse:

Employer:

Phone:

Person Responsible for the account:

Contact in case of an Emergency: Name

Relationship to patient:

Address:

Phone:

Dental Insurance Information

Name of Dental Insurance Company:

Phone:

Primary Policy Holders Information:

Name of Insured (Primary Policy Holder):

Date of Birth (Policy Holder):

SS#/ID #(Policy Holder)

Group #

Employer:

I authorize Circle C/Del Toro Orthodontics to accept assignments of all insurance benefits. If we do not accept assignment from your insurance provider, we will gladly assist you in submitting your claim forms regarding any charge for care in our office.

Patient/Guardian Signature:

Date

Photo Permission Form

You have been provided with a Privacy Notice as required by the United States Department of Health and Human Services. Fidel Del Toro, DDS, PhD, Jonathon Kimes, DDS, Circle C Orthodontics PLLC, and Del Toro Orthodontics make every effort to comply with each of the rules that apply to all protected health information. You are now being asked to amend the Privacy Notice for the following reasons and purposes:

Drs. Del Toro and Kimes maintain a website (www.austin-braces.com) as well as various social media sites (Facebook, Twitter, Instagram, etc.) for the purpose of conveying information to current and prospective patients. In order to keep these sites relevant we occasionally post photographs of current events in the practice as well as before and after photographs of our patients’ teeth.

For the purpose of the website, we only post close up photographs of the teeth with no identifying information (faces, names, etc.). For social media uses we post various photograph of patients and their accomplishments. These photographs will be full pictures that show the patients’ faces and sometimes first name only. We will not provide any other identifying information (last name e.g.).

I consent to the use of close-up photographs of the teeth for the practice website.

I consent to the use of full photographs for social media.

I decline the use of any photographs.

Date:

Patient/Guardian Signature:

Amendment to Privacy Health Information Notice

You have been provided with a Privacy Notice as required by the United States Department of Health and Human Services. Circle C Orthodontics, PLLC makes every effort to comply with each of the rules that apply to all protected health information. You are now being asked to amend the Privacy Notice for the following reasons and purposes:

Dr. Del Toro is an Assistant Professor at the University of Texas Health Science Center in San Antonio Dental School and MAY use your x-rays, pictures, or dental models for teaching, lecturing, research or publishing in scientific journals. At NO time will your name (or your dependent's name) or other personal information (phone number, insurance information, etc.) be used for teaching, lecturing, research or publishing purposes.

This amendment and potential use of x-rays, pictures, or dental models will be in effect until Dr. Del Toro is no longer teaching, lecturing, carrying out research or publishing in scientific journals. You do retain your rights to revoke consent of this amendment at any time.

I accept I decline

Person accepting Amendment (print name):

Date

Patient/Guardian Signature:

If other than the patient, indicate relationship:

Privacy Notice

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 numbers, 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 (your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you or your dependent;
To third party payors (insurance companies, administrators of flexible spending accounts, etc.) in order to obtain payment of your account;
To certifying, licensing and accrediting bodies 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.; and/or,
To family members involved in your treatment, including appointment reminders by phone or mail. Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

Request restrictions on the use and disclosure of your protected health information;
Request confidential communication of your protected health information;
Inspect and obtain copies of your protected health information through asking us;
Amend or modify your protected health information in certain circumstances
Receive an accounting of certain disclosures made by us of your protected health information; and,
You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information; and
To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

Honor any request by you to restrict the use or disclosure of your protected health information for treatment, payment or healthcare operations;
Amend your protected health information if, for example, it is accurate and complete; or
Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This privacy notice is effective as of the date of your signature. By signing, you acknowledge that you have reviewed a copy of this Notice. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person. Thank you.

Patient’s Signature (Legal guardian if minor)

Date

ORTHODONTISTS
Fidel Del Toro, DDS, PhD
Jonathon Kimes, DDS

5700 W. Slaughter Lane #300

Austin, TX 78749

Phone: (512) 394-0930

Fax: (512) 394-0946

www.austin-braces.com

WELCOME TO OUR OFFICE

ADULT PATIENT INFORMATION:

Family and Account Information:

Dental Insurance Information

Primary Policy Holders Information:

ORTHODONTISTS
Fidel Del Toro, DDS, PhD
Jonathon Kimes, DDS

5700 W. Slaughter Lane #300

Austin, TX 78749

Phone: (512) 394-0930

Fax: (512) 394-0946

www.austin-braces.com

Patient Health History:

Photo Permission Form

Amendment to Privacy Health Information Notice

Privacy Notice

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.

ORTHODONTISTS Fidel Del Toro, DDS, PhD Jonathon Kimes, DDS

5700 W. Slaughter Lane #300

Austin, TX 78749

Phone: (512) 394-0930

Fax: (512) 394-0946

www.austin-braces.com

WELCOME TO OUR OFFICE

ADULT PATIENT INFORMATION:

Family and Account Information:

Dental Insurance Information

Primary Policy Holders Information:

ORTHODONTISTS Fidel Del Toro, DDS, PhD Jonathon Kimes, DDS

5700 W. Slaughter Lane #300

Austin, TX 78749

Phone: (512) 394-0930

Fax: (512) 394-0946

www.austin-braces.com

Patient Health History:

Photo Permission Form

Amendment to Privacy Health Information Notice

Privacy Notice

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.

ORTHODONTISTS
Fidel Del Toro, DDS, PhD
Jonathon Kimes, DDS

ORTHODONTISTS
Fidel Del Toro, DDS, PhD
Jonathon Kimes, DDS