Adult Health History Form | Rothenberg Orthodontics

Date:

PATIENT INFORMATION

Patient's Name:

Nickname:

Date of Birth:

Home Phone:

Home Street Address:

City, State, Zip Code:

Cell Phone:

Email:

Preferred Method of Contact (circle one):

Home Phone

Cell Phone

Email Address

Spouse's Name:

Date of Birth:

Cell Phone:

Email:

Number of children in the family:

Names and ages:

Person responsible for patient account:

If responsible party is someone other than you (the patient) please provide the following:

Name:

Address:

Phone Number:

Email address:

Patient's General/Pediatric Dentist:

Whom may with thank for referring you to our office?

What goal(s) are you looking to accomplish with orthodontic treatment?

This notice describes how medical/dental information about a patient may be used and disclosed. Please read carefully.

Protected Health Information (PHI) is information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health-care services. This notice of privacy practices describes a patient's rights and how the office of Jason T. Rothenberg, DMD, MS may use and disclose PHI to carry out treatment, payment (insurance submission), health care operations, and for other purposes permitted or required by law.

Jason T. Rothenberg, DMD, MS will not use or disclose PHI about a patient without your or a legal guardian's written permission, except as described in this notice. We are required by law to maintain the privacy of PHI and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We are also required to abide by the terms of this notice of privacy practices. We may change our practices and this notice and make the new notice effective for the PHI we maintain. If you request it, we will provide you with a revised notice.

Your Rights:
You may obtain a paper copy of our Notice of Privacy Practices upon request at any time.

You may inspect and obtain a copy of your PHI, which usually includes patient information, course of treatment, x-rays, and billing information. We may charge you for copying and mailing, and any supplies needed to fulfill your request. We may deny your request in certain instances, and you may ask to have you denial reviewed.

You may request a change to your PHI. If you review you PHI and find information incomplete or incorrect, you may request an amendment to it for as long as we maintain your PHI. You may request a restriction of your PHI. This means that you may ask us not to disclose or use any part of your PHI for purposes of treatment, payment, or healthcare operations. You may also request that you PHI not be disclosed to certain family members, legal guardians, or friends who may be involved in your care. You must list the individuals to whom you want the restrictions to apply. We are not required to agree to a requested restriction.

How we May Use and Disclose PHI:
For treatment purposes including, but not limited to: treatment planning; healthcare operations; health-related communications to individuals involved in your care or payment for your care.

For payment and insurance information.

For public safety related operations including, but not limited to: the FDA; worker's compensation; public health or disease control; law enforcement officials; coroners, medical examiners, and funeral directors; correctional facilities; military authorities; issues of National security; or victims of abuse, neglect, or domestic violence.

Please notify the office of Jason T. Rothenberg, DMD, MS if you have any questions related to this notice.

I have received a copy of this notice.

Patient Name:

Patient/Guardian Signature:

Click and drag inside the box to write your signature.

Date:

PATIENT'S NAME:

DATE OF BIRTH:

PRIMARY INSURANCE

EMPLOYEE NAME:

EMPLOYEE SSN:

DATE OF BIRTH:

EMPLOYER NAME AND ADDRESS:

INSURANCE COMPANY NAME:

POLICY #:

GROUP #:

SECONDARY INSURANCE

EMPLOYEE NAME:

EMPLOYEE SSN:

DATE OF BIRTH:

EMPLOYER NAME AND ADDRESS:

INSURANCE COMPANY NAME:

POLICY #:

GROUP #:

SIGNATURE:

Click and drag inside the box to write your signature.

DATE:

Until I tell you in writing to stop, I authorize Dr. Jason Rothenberg to transmit patient information relating to my treatment, health, or payment by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment, payment for my treatment, or Dr. Jason Rothenberg's health care operations. The patient information that may be emailed may include my x-rays. health history, diagnosis, treatment, and payment records.

I understand that:

I do not have to sign this form.
My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.
If I don't sign this form, Dr. Jason Rothenberg may use other ways to send my information, such as U.S.-Mail, or may ask me to send my information to third parties myself.
There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by privacy law.
Dr. Jason Rothenberg does not email such sensitive personal information as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that Dr. Jason Rothenberg already sent before receiving my written instructions to stop.

Patient Name:

Signature:

Click and drag inside the box to write your signature.

Date:

Rothenberg Orthodontics - New Patient Questionnaire for Adult Patients

Madison Office

PATIENT INFORMATION

DENTAL HISTORY

TMJ HISTORY

AIRWAY/SLEEP HISTORY

MEDICAL HISTORY

ALLERGIES

JASON T. ROTHENBERG, DMD, MS
Notice of Privacy Practices

ROTHENBERG ORTHODONTICS
333 MAIN STREET
MADISON, NJ 07940
(973) 822-2308
ORTHODONTIC INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

Authorization and Consent
To Send Unencrypted Patient Information by Email and Other Electronic Means

Rothenberg Orthodontics - New Patient Questionnaire for Adult Patients

Madison Office

PATIENT INFORMATION

DENTAL HISTORY

TMJ HISTORY

AIRWAY/SLEEP HISTORY

MEDICAL HISTORY

ALLERGIES

JASON T. ROTHENBERG, DMD, MS Notice of Privacy Practices

ROTHENBERG ORTHODONTICS 333 MAIN STREET MADISON, NJ 07940 (973) 822-2308 ORTHODONTIC INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

Authorization and ConsentTo Send Unencrypted Patient Information by Email and Other Electronic Means

JASON T. ROTHENBERG, DMD, MS
Notice of Privacy Practices

ROTHENBERG ORTHODONTICS
333 MAIN STREET
MADISON, NJ 07940
(973) 822-2308
ORTHODONTIC INSURANCE INFORMATION

Authorization and Consent
To Send Unencrypted Patient Information by Email and Other Electronic Means